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AL TO~ ODOT FUELS TAX GROUP F ~L TAX ~FL~N
<br />M 55o CAPITAL ST NE
<br />SALEM 0R 97301-2530 CITY OF EUGENE .
<br />PHONE. X503) 378-815 FAX: ~~03} 378-3o~a ~
<br />~vww.ore on,, ov~odo~,~ F®~m ~ 244 07!09
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<br />N ~ , _ ~ ~ , 1. Name of Claimant ~ ~,T
<br />PLEASE PRINT ~ 4 SOCIAL SECURITY oR~ElN NUMBER R 2. Address
<br />.rend' L - ~ c, 3 s~REET o~ RourE ANC aox # ~ CITY sTA~"E z!P conE 4
<br />3. Principal Business Do you sell fuel to others? IrrA~IrIIIliIrrAAAAAAAA1~IrIIrAAAAAArw'
<br />4. Contact Information . ~ ~ f ~ ,
<br />TELEPHQNE INCLUDE AREA CODE FAX NUMBER INCLUDE AREA CavE E-MAIL ADpRESS
<br />5. Claim Period: ~ TO Date of last CIaIm; AAArrIIXrfIA ~AAArr uH"AAAAAAAAAr.r orrreeuwlnrrrAArArr~ -
<br />GALLONS
<br />FUEL PURCHASED, USED AND STORED: Round to nearest whole gallon
<br />5, Beginning Inventory on Hand fending inventory from prior claim} , A A . , A . , . , r , , , , .Y A,. YY j 1 TY A,~~A 7. Add Fuel Purchased this Period attach vrl final invoices for
<br />urchases
<br />. ~ g p } ,..A........A..A... ~ ~li it IAI rrrr~IlrrlrArr . Total FueltvAccountFor ~line6+line7}.,,.....AA1ArA.,A.1.,rA,..,A..,A..,....r.~.. .
<br />9. Deduct Inventory on Hand at end of Period beginning inventory for next claim period} . , , . , . , A
<br />1 .Ili~ri~rl..l.,. 14. Deduct Fuel used in a non refundable manner I r , A , . _ .....,.A1..A•...A,.....AA..A.rr,..AA.
<br />11ATotalFueldeductions~line9+Ilne10}..,....AA...AA...A.,A..,..A
<br />12, Total Refundable Fuel Used~line8-line 1l}A,1,.A,ArA,,,AA,,,Ar,I.AA,rrrAAlr....
<br />13, Amount Claimed far Refund dine 12 x $0.05 per gallon} .1 . . . . . . . . . A , , , . , , . .r.
<br />INDICATE TYPES} OF REFUNDABLE USAGE BELDVV, PR®VIDING DETAIL aN THE ~ACKAS REQU9RED GALLONS
<br />14. NON VEHICULAR ENGlNES1EQUIPMENT AND UNLICENSED VEHICLES I<Tvtal from section 2 Line 1~
<br />15. LICENSED VEHICLE USE ON PRIVATE PROPERTY farm and non farm use ~Totai from section 2 Line 2}
<br />1 \/r COMMERCIAL MOTOR BOAT USE: Describe use
<br />Boat or Vessel reg # AND Commercial or Charter license # 17r OTHER REFUNDABLE U5E Total from section 2 Line 3)
<br />18. EXPORTED IN VEHICLE TAN14 attach proof of tax paid to another state
<br />19. GOVERNMENTAL AGENCY USE
<br />20r TOTAL REFUNDABLE USE (add lines 14 through 19, should equal line 12 above} -
<br />SECTION 1: FUEL STORAGE must be o~mplete f®r all claims
<br />1 A How do you acquire your fuel check all that apply}
<br />Bulk Cardlock Retail Other please explain}:
<br />2. How do you store your fuel: Complete if you maintain any storage} Use; On raad, off 31 Da you maintain separate
<br />Tank Mist by name or number} Contents fuel type} road or both storage for yaur refundable
<br />and nonrefundable use? ~ ~ r~C1111 III11~
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<br />~~~..y~.IW X1111 II~Y.~.W~rW11YYYr~IAII~lYWI1111rArA~ IIIr-
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<br />NO
<br />If addltlonal space Is needed, please attach a separate sheet.
<br />®r. ~~~rf~nue a~a ~~h~r
<br />By signing below, I hereby certify that I have full knowledge of this claim, that the fuel was purchased on the dates and in the amounts shown on each invoice; that the fuel has been
<br />use by claimant in the manner set forth above and that none of the fuel on which a tax refund is claimed was used far operating or 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 .INANIIIAAr~ep 11 IA~AAITIIIiIINI~glrllillllr~yllnrl r1AAlAMr IIMl~rllrrrrrrrllrllrirfll I ~i11MirY11Y~IiINIM YA 111 lYYrYlr~r~.~mulur_u' II rllYl
<br />PRINT NAME PRINT NAME r ~ s G i, ~ . I RIIRIINIpAAAAlllll11111 IIIIrr~~,lAri~
<br />ADDRESS DATE
<br />PHONE NUMBER TITLE r AAAAYwIrIAAIr_AlArrII IIIIIIIIrrIIAArIArllrrllilli llr luI IIA ---Irlllillr n ~ ~ -
<br />DQ NaT WRITE ~ELOw THIS LINE
<br />Codes; county state Federal Remarks
<br />Approved for Payment: Director, Dept of Transportation, by
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