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<br />oDOT FUELS~TAxGROUP ~L TAX ~F~J CLAD
<br />55a CAPITOL ST NE
<br />SALEM OR a73a~-2530 CITY 4F EUGENE PHONE: ~5a3) 318-895a .
<br />FAX: ~ba3~ 378-306a
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<br />1, Name of Claimant 1, _ _
<br />PLE4SE PRINT' soclAL sECURI~r~r os ElN NUMBER 21 Address
<br />STREET OR RDUTE AND BQX # ' . CITY: 5~ IIZIP CQDE
<br />3, Principal Business _ v Do you sell fuel to others? _~r9~1 ~ Il lallri~ll II IIIIIIII IlYllnlll~ lIIYIIIIIIIIIII`
<br />4. Contact Information ~
<br />ss TELEPFIaNE INCLUDE AREA CaDE FAx NUMBER INCLUDE AREA CODE ~-MAIL ADDRESS
<br />5. Claim Period: TO Date of last Claim:
<br />GALLONS
<br />FUEL PURCHASED, USED AND STORED: {Round to nearest whale gallant 5. Beginning Inventory on Hand fending inventory from prior claim3 . . . . . . . . . . .
<br />Y II ~ AI WMY 7. Add Fuel Purchased this Period attach original invoices for purchases} . . . . . . . - 1 ~ 1.;`I
<br />8, Total Fuel to Account For dine 6 + line 7~ . ......11, , Y 1.... , , , - ~ ~
<br />9, Deduct Inventory on Hand at end of Period beginning inventory for next claim periods , , ~ 111.11.,~...~..11.
<br />10. Deduct Fuel used in a non refundable manner . . . . . . . 11. Total Fuel deductions~line9+Iine10} ..,11„
<br />1~ 12, Total Refundable Fuel Used dine 8 -line 11 ~ . Y ,
<br />13. Amount Claimed for Refund dine 12 x $O.o5 per gallon .................................1 I I I 11 1~~ 111/jIIIw.~WI
<br />INDICATE TYP~~Sy OF REFUNDABLE USAGE BELOW, PROVIDING DETAIL ON THE RACK AS REQUIRED GALLONS
<br />14. NON VEHICULAR ENGINESIEQUIPMENTRND UNLICENSED VEHICLES Total from section 2 Line 1 ~
<br />15, LICENSED VEHICLE USE ON PRIVATE PROPERTY farm and non farm use (Total from section 2 Line 2~
<br />16. COMMERCIAL MOTOR BOAT USE: Describe use
<br />Boat ar Vessel reg # AND Commercial or Charter license #
<br />1 T, OTHER REFUNDABLE USE ~Tatal from section 2 Line 3} 18. EXPORTED IN VEHICLE TANK attach proof of tax paid to another state
<br />19. GOVERNMENTAL AGENCY USE
<br />20. TOTAL REFUNDABLE USE (add lines 14 through 19, should equal line ~2 abave~ `
<br />SECTION 1:FUEL STORAGE ~musf be complete for all clalmsy
<br />1, Haw do you acquire your fuel check all that apply}
<br />Bulk Cardlock Retail Other please explain}: •
<br />2, Haw do you store your fuel: Complete if you maintain any storage} Use: On road, off 3, Do you maintain separate
<br />Tank Mist by name or numbers Contents fuel type) road or both storage for your refundable
<br />A and nonrefundable use? ~1. II IIILY~^_
<br />I J.L-_... c: ~ III fr~i~ ~~r Yg i.IW1YW1Y,Y15rrdWa~L. iYW'" L` w!Y.~n~n~il I ~wr tYl
<br />Yes .~.......~~.I II.I..I.YIY... . , . ~I YYi I YI f
<br />1 7 I ~W Ilw nYl'Y`I~1 I II IYYIY~u II I / 1 1"'" IhI11WIYWYF VWYYY~~wWrl~`~e~.l.
<br />» 111 I I II~IIIn111PI I~IIY~PIII lll~.epwp ~ . N o if additional space is needed, please attach a separate sheet.
<br />~~r~a con~ilnc~e~ other sf~eY,
<br />ey signing below, l hereby certify that I have full knowledge of this claim, that the fuel was purchased on the dates and in the amoun#s shown on each invoice; that the fuel has been
<br />use by claimant in the manner set Earth above and that Wane of the fuel on which a tax refund is claimed was used for operating or propelling motor vehicles upon any state highway, county
<br />road, city street, or upon any other highway, except as authorized by QR5 319; and #hat no part of the tax refund claimed has been paid,
<br />PERSON OTHER THAN CLAIMANT PREPARING CLAIM CLAIMANT
<br />SIGNATURE CLAIMANT SIGNATURE ;fx
<br />PRINT NAME PRINT NAME ,WYI.Y I I II ' u I 1:..`:..Ir~ r - 1
<br />ADDRESS DATE ' PHONE NUMBER
<br />TITLE _ - W II 1 ~1 11.11'1 pn1Y~nYY1w.Y I I YYIY I I` '
<br />DO NOT WRITE BELOW THIS LINE
<br />Codes: County State Federal Remarlt5
<br />Approved for Payment: Director, Dept of Transportation, by
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