MR70

MR70

Customer ID*

Application for refund of fuel excise duty and motor vehicle account fuel levies

Please tick one box only

PetrolLPGCNG

Excise Refund Customer Number

Please tick if this is your first fuel excise duty refund claim

Applicant details

Initials & surname or company name

Mailing address

Town

Email address

example@example.com

Claim for quarter ending

	Tick the relevant Quarter	Year
31 Mar
30 Jun
30 Sep
31 Dec

Commercial activity for which the claim is being lodged

Part A: Purchases (only purchases or deliveries made within the quarter can be included in claim)

	No. of litres or GJ (CNG claims only)
Opening balance/carried over from previous quarter - taken from box 3 last claim (1)
Total purchases - complete schedule on page 3 and transfer total (2)
Add boxes 1 and 2 – this is total fuel available for use - TOTAL A
Closing balance/on hand end of quarter – this is box 1 next claim (3)
Ineligible use – use on public roads, non-commercial use, private use (4)
Add boxes 3 and 4 - this is fuel not able to be claimed - TOTAL B
Subtract TOTAL B from TOTAL A - this is the total fuel claimed for refund: TOTAL C

Additional Subtotal Page 1

Additional Subtotal Page 2

LPG applications only

	Open	Closed
Automotive pump reading

Part B: How was Total C fuel used
Important: Applicants must check that Total D is equal to Total C.

1. Vehicles currently licensed in classes A or B

	Make/model	Plate number	Litres/GJ used (not on public roads)
1.
2.

Total 1


Total 1 (include subtotals from page 2 as applicable)

Unregistered vehicles vehicle = a conveyance that transports people or objects

	Make/model	VIN/chassis	Year of manufacture	Litres/GJ used
1.
2.
3.

Total 2

3. Commercialpurposes(not vehicles)

	Type	Quantity	Litres/GJ used
Specify all machinery 1.
2.

Total 3

4. Vehicles subject to road user charges

	Plate number	Current hubodometer reading	RUC paid to	Litres/GJ used

Total 4

5. Commercial vessels

	Name of vessel	Maritime safety no.	Expiry date	Litres/GJ used

Total 5

TOTAL D

WARNING:ANY PERSON MAKING A CLAIM OR FURNISHING ANY INFORMATION KNOWN TO BE FALSE IN ANY MATERIAL PARTICULAR IS LIABLE FOR PROSECUTION.

I certify that the particulars shown above are correct.

Authorised Signature*

Enter your Name here

Phone No:

Print name

Date*

Date

Part B: How was Total C fuel used (continued)

Vehicles currently licensed in classes A or B

	Make/model	Plate number	Litres/GJ used (not on public roads)
1.
2.
3.
4.
5.
6.
7.
8.

SUBTOTAL 1

2. Unregistered vehicles (vehicle = a conveyance)

	Make/model	VIN/chassis	Year of manufacture	Litres/GJ used
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6
Vehicle 7
Vehicle 8
Vehicle 9
Vehicle 10
Vehicle 11
Vehicle 12

Subtotal 2

3. Commercial purposes(not vehicles) Specify all machinery

	Type	Quantity	Litres/GJ used
1.
2.
3.
4.
5.
6.
7.

Subtotal 3

4. Vehicles subject to road user charges

	Plate number	Current hubodometer reading	RUC paid to	Litres/GJ used
1.
2.

Subtotal 4

5. Commercial vessels

	Name of vessel	Maritime safety no.	Expiry date	Litres/GJ used
Vessel 1.
Vessel 2.
Vessel 3.

Subtotal 5

SCHEDULE OF PURCHASES

	Name of and location of vendor (or bulk delivery provider)	Type of fuel (include octane rating)	Purchase/delivery date (must fall within quarter)	No. of litres

TOTAL