N.H. Admin. Code § Saf-C 311.25 - Form RT 122G Road Toll Refund General Application - Gasoline Only

(a) An applicant shall submit the following on form RT 122G:

(1) Applicant's name, address and telephone number;

(2) Federal employer identification number, if applicable;

(3) Applicant's claim, including:

a. Total gallons per invoice;

b. Total gallons consumed on public ways;

c. Total gallons consumed off public ways; and

d. Dollar amount of refund request.

(4) Type of operation;

(5) City or town and state where gallons were used;

(6) Period covered;

(7) Vehicle or equipment type, make and year;

(8) Registration number of vehicle or serial number of equipment;

(9) Itemized gallons used on highway;

(10) Itemized gallons used off highway;

(11) Total gallons used on highway;

(12) Total gallons used off highway;

(13) Grand total of gallons used on and off highway; and

(14) Stock record, including:

a. Actual inventory;

b. Total gallons per invoice;

c. Total gallons to be accounted for;

d. Total gallons used;

e. Total gallons sold;

f. Book inventory on the last day of the period;

g. Actual inventory on the last day of the period;

h. Stock loss or gain; and

i. Total gallons accounted for.

(b) The applicant shall sign the form.

Notes

N.H. Admin. Code § Saf-C 311.25

(See Revision Notes #1 and #2 at chapter heading for Saf-C 300) #10032, eff 11-22-11

Renumbered From Saf-C 311.23 Volume XXXV Number 1, Filed January 8, 2015, Proposed by #10753, Effective 1/1/2015.