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<br />OQOT FuEI~ CROUP U ~ L ~ ,y r~~,.,
<br />554 CAPITOL ST NE SALEM OR 97341-~53o CITE ~F EUGENE ~ : ~~~~"~y
<br />PHONE. ~503~ 3~~-150
<br />FAX: (503 378.3060 ~ . w r v do ~ ~~04 47~0~
<br />~ 7
<br />m
<br />1. Name of Claimant m ~ ~ ~ - ~ d
<br />LEASE PRINT , SOCIAL SECURnY OR EIN NUMBER Z. Address ~ yx~.., ~ ~ ~ ~ ~ t
<br />STREET OR t~OUTE AND 8O ~ ~ d STATE ZIP CODE
<br />3. Principal Business Do you sell fuel to others?
<br />4. Contact Information ~ ~ ~ ~a. ( ~ - ~ ~ ~ a ~ a t~ ~ e~
<br />TELEPHONE INCLUDE AREA CODE 1=Ax NUMBER INCLUDE AREA CODE EMAIL ApDRE55 5. Claim Period: t ~ ~ TO ~ ~ Date of last Claim:
<br />GALLONS FUEL PURCHASED, USED AND STORED. (Round to nearest whole gailan)
<br />6. Beginning Inventory on Hand (ending inventory from prior claim} , , , , , , , , , , , , , , , , , , , , , ~ , ,
<br />7. Add Fuel Purchased this Period attach original invoices for purchases} , , , , , , , , , , , , , ,
<br />5. Total Fuel to Account For (line 5 + line . . . . . . . . . 1
<br />9. Deduct Inventory on Hand at end of Period beginning inventory for next claim period} . , , , , , ° ~s . 10. Deduct Fuel usedlnanonrefundablemanner,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
<br />11. Total Fuel deductions(line9+li.ne10}
<br />r 12. Total Refundable Fuel Used (line S -line 11 } . . . . . . . , , . .
<br />13. Amount Claimed for Refund aline 1 Z x $0.05 per gallon} , itilnlmini~~~ewii it iwn
<br />INDICATE TYPES} OF REFUNDABLE USAGE BEL®Vy, PROVIDING .DETAIL aN TWE SACK AS aEQUIRED 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 Pram section 2 line 2~
<br />1 G. COMMERCIAL MOTDR BOAT USE: Describe use
<br />Boat or Vessel reg # ~ AND Commercial or Charter license # 17.OTHER REFUNDABLE USE (Total Pram section 2 Line 3~
<br />18. EXPORTED IN VEHICLE TANI6 attach praaf of tax paid to another. state
<br />19. GOVERNMENTAL AGENCY USE
<br />20. TOTAL REFUNDABLE USE (add lines 14 through 19, should equal line ~Z abave}
<br />SECTION FUEL STORAGE (must be complete for aI claims}
<br />1. How 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: Dn road, off 3. Da you maintain separate
<br />Tank list by name or number} Contents (fuel type) road or bath storage far your refundable
<br />~ and nonrefundable use? ~ ~ a .k
<br />~ ~ . Yes i '~qi we ~ ~ ~Ip..l~l~ @ ~ ~k M
<br />" No
<br />If addlt€onal space Is needed, please attach a separate sheet.
<br />ey signing below, I hereby certify that 1 have full knowledge of this claim, that the fuel was purchased on the dates and in the amounts shown on each invoice; that the foal has assn
<br />use by claimant in the manner set forth above and that Wane of the fuel on which a tax refund is claimed was used for operating ar propelling motor vehicles upon any state highway, county
<br />road, city street, or upon any other highway, except as authorized by ORS 319; and that no part of the tax refund claimed has been paid,
<br />PERSON OTHER THAN CLAIMANT PREPARING CLAIM CLAIMANT
<br />SIGNATURE CLAIMANT SIGNATURE
<br />PRINT NAME PRINT NAME >s ADDRESS DATE
<br />PHONE NUMBER TITLE ~ ~
<br />DO NOT WRITE SELOw THIS LINE
<br />Codes: county state rederal Remarks
<br />Approved far Payment; Director, Dept of Transportation, by
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