Application for Refund of Gasoline Tax

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Application for Refund of Gasoline Tax
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Application for Refund of Gasoline Tax
(Pursuant to the Prince Edward Island Gasoline Tax Act
and the Revenue Administration Act R.S.P.E.I. 1988)
M ail to:
Finance, Energy and Municipal Affairs, Taxation and Property Records
PO Box 1150, Charlottetown, PE C1A 7M8
For more information:
Tel: (902) 368 5703
Fax: (902) 368 6164
W ebsite: www.taxandland.pe.ca
Em ail: [email protected]
Deliver to:
95 Rochford Street
Shaw Building, 1 st Floor
Charlottetown, PE C1A 3T6
or: any Access PEI Centre
Freedom of Information and Protection of Privacy
Personal information on this form is collected under the authority of Section 31(c) of the Freedom of Information and Protection of Privacy Act and
will be used for the purposes of tax administration and enforcement. Questions on the collection and use of this information can be directed to the
Manager, Corporate and Tax Administration Services, PO Box 2000, Charlottetown, PE C1A 7N8 (902) 368-5137.
Please complete all sections in detail
Section A – Claimant Information (please print)
Nam e [must include m iddle nam e(s)] :
Nature of Business (if applicable): Fishing “
Farming “
Aquaculture “
Silviculture “
Other:
M ailing Address:
City/Tow n/Village:
Province:
Telephone:
Cell:
Postal Code:
Fax:
E-m ail:
Section B – Refund Information
1. Marked Gasoline and/or Marked Diesel Oil Perm it No.
2. Period of Claim (dates)
20
to
20
3. Com plete schedule on reverse and attach all original receipts .
4. Brief description of the reason for requesting the refund. Attach a separate sheet if required.
5. List all vehicles and equipm ent that were refueled from the purchases listed on reverse. Attach a separate sheet if
required.
Section C – Refund Requested
Total product purchased:
litres
Total product on which refund is requested:
litres @
per litre = $
Section D - Certification
I certify that the information herein is accurate and complete. I understand that it is an offence, subject to prosecution under the
Revenue Administration Act, to make any false statement(s) on this application. I authorize any inspector under the Revenue
Administration Act or any peace officer to inspect my books and records, vehicles or premises and to open any storage tank and
remove therefrom any quantity of gasoline or diesel oil sufficient in their opinion, for the purposes of determining whether there has
been compliance with the Gasoline Tax Act.
Name (please print)
Title
Signature
Date
December 2011
Telephone
11PT15-30638
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Below, list all purchases (by date) of product and attach all original invoices.
(Attach a separate sheet if required.)
Date
Name of Supplier
Invoice Number
Total Taxed Product Purchased (enter in Section C on reverse)
For Office Use Only
Application status:
Signature:
Com m ents:
Approved Q
Denied Q
Client Access No. :
Taxed Litres
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