Application Form for Refund of Provincial Fuel Tax on by hxx21282

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									                                   Service Nova Scotia
                                   and M unicipal Relations
                                                                                       Nova Scotia
                                   Refund Section                    Receipt Based Claim for Status Indians
                                   PO Box 1523
                                   Halifax, NS     B3J 2Y4                          Refund Application
                                                                                         (Please Print)

1. Give us your details.
 Given Name:
                                        First                            Middle                     Last


 Civic Address
 (Not a PO Box)              Civic #                    Street/Road/Hwy                     Unit/Suite/Apt #



                             City/Town/County                            Province                   Postal Code


 Mailing Address
 (If different from above)              PO Box or RR



                                        City/Town/County                 Province                   Postal Code


 Home Phone:                                                             Fax Number:

 Work Phone:                                                             Email:
2. Provide your Driver’s Licence Information.
   Driver’s License Master #                                                           Province of Issue

3. Provide your Indian Status Information.
  Indian Band:                                                     Band Number: :
                              (Registry Group)


  Based in Province of                                             Registry Number:

4. Provide Information on NSIFTEP status.
Are you registered under the Nova Scotia Indian Fuel Tax Exemption Program (NSIFTEP)? Yes G No G

If Yes, provide name and address used on NSIFTEP registration if different.

Given Name:
                                       First                             Middle                              Last


Civic Address
(Not a PO Box)           Civic #                       Street/Road/Hwy                    Unit/Suite/Apt #



                         City/Town/County                                Province                  Postal Code




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5. Provide Information on your Refund Claim
Is this your first application for a refund of Nova Scotia fuel tax?                 Yes G No G

If No, provide name and address used on your last refund claim if different.

Given Name:
                                  First                             Middle                                    Last


Civic Address
(Not a PO Box)          Civic #                  Street/Road/Hwy                           Unit/Suite/Apt #



                        City/Town/County                            Province                       Postal Code

6. Provide claim period: From                                      , 20         to                                   , 20
                                           ( Month )   ( Day )                         ( Month )          ( Day )

7. Calculate your claim (See table of historical fuel tax rates from April 30, 1994 forward on page 4)
                       Litres Claimed
  Product            (From Schedule A)                     Tax Rate
   Gasoline                                    litres at         $0.155      cents per litre =        $
   Diesel Fuel                                 litres at         $0.154      cents per litre =
   Propane                                     litres at         $0.070      cents per litre =
   Marine Fuel                                 litres at         $0.011      cents per litre =
   Aviation Fuel                               litres at         $0.025      cents per litre =
   Total Litres                                                              Total Refund Claim       $
 8. Sign the Certification
I hereby certify that:
       (1) The information provided in this application is true, complete and correct in every respect.
       (2) I am the person described on this form and entitled to the amount claimed.
       (3) The fuel purchases covered by this claim were for my own use and not for resale.
       (4) This amount has not been previously claimed.
       (5) All relevant records are available for inspection.
       (6) Copies of all invoices/documents are attached.


       Signature of Applicant                                                                                 Date

Note: It is a serious offence to make a false application for refund.


Office Use Only:

Amount Claimed                                         Authorized by

Adjustments                                            Date:

Amount Approved



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                                                   Schedule A
List in chronological order the details of all unpaid invoices on which a rebate of fuel tax is claimed.
Attach a copy of all invoices. Attach additional schedules if required.

         Name on Invoice                       Location       Invoice No.   Invoice date      Litres




                                                                            Total Litres

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 INSTRUCTIONS, CONDITIONS AND CONTACT INFORMATION
 1. It is suggested that you submit a claim only when the amount of tax is $100.00 or greater. Refund
    claims for less than $100.00 should only be submitted on an annual basis.

 2. Please provide a copy of your band card (front and back).

 3. Ensure that your fuel purchases are either from service stations located on Reserves or bulk
    deliveries made to Reserves, in Nova Scotia.

 4. If your fuel purchases were made on credit, please be advised that we may verify that the credit
    transactions have been paid in full.

 5. For fuel purchases prior to January 1, 2003, a separate refund claim must be filed. Also, a special
    release must be signed by the claimant in respect of each Reserve on which the fuel was
    purchased. The appropriate release form(s) will be sent to you after receipt and review of your
    refund claim.

 6. It is necessary to submit copies of all documents (e.g. invoices) that support your claim.

 7. Sufficient records must be retained to support your claim and must be produced if requested by an
    auditor or other authorized official appointed under the Revenue Act.

 8. Return the original copy of the rebate application to:

 By Mail:                                                 By Delivery:

 Service Nova Scotia and Municipal Relations              Service Nova Scotia and Municipal Relations
 Business Registration Unit                               Business Registration Unit
 Refund Section                                           Refund Section
 PO Box 1523                                              Maritime Centre, 9th Floor North
 Halifax, NS                                              1505 Barrington Street
 B3J 2Y3                                                  Halifax, Nova Scotia


For more information

Website:      gov.ns.ca/snsmr/access/business/tax-comm/

Call:         424-6300 (metro) or 1-800-565-2336 toll free in Nova Scotia


                                         Historical Fuel Tax Rates Per Litre


Effective Date                            Gasoline      Diesel Oil       Propane     Aviation      Marine
Apr 30, 1994                               $0.135        $0.154           $0.135     $0.009        $0.011
Apr 26, 1996                               $0.135        $0.154           $0.070     $0.009        $0.011
Apr 05, 2002                               $0.155        $0.154           $0.070     $0.009        $0.011
Mar 24, 2007                               $0.155        $0.154           $0.070     $0.025        $0.011




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