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DR 7189 (09/09/13)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0009                                                                                 *147189==19999*
(303) 205-8205
                                                                             Registration/Permit Number (Department Use Only)

                  Gasoline/Special Fuel                                                   General Partnership         Individual
      Tax Refund Permit Application                                                        Limited Partnership        Corporation
                                                                                          Government                  Other

                                                                             If other, specify:

I. Business Information
Last Name or Business Name                                        First Name                                        Middle Initial

Trade Name                                                                   FEIN                                SSN (required)

City limits in which business is located (if applicable)          County in which business is located

Business Location Address                                                                            Phone Number
                                                                                                     (          )
City                                                                                                 State       Zip

Mailing Address

City                                                                                                 State       Zip

II. Check box of fuel type for you will request refunds

     Special Fuel                                        Gasoline                       Aviation Jet Fuel

     Aviation Gasoline                                   Gasohol (includes E10 and E85) Compressed Natural Gas

     Liquified Natural Gas                               LPG

Enter total fuel capacity of storage tanks:
Aviation Gasoline             Special Fuel                                              Gasoline/Gasohol
                               
Aviation Jet Fuel             LPG                                                       Liquid Natural Gas

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*147189==29999*

III. Circle Only One classification code that best describes your business. (In the case of multiplies uses, circle
the code where the bulk of the fuel is used.) Provide a description of your business in Part IV.

Services - Commercial 23. Farm/Ranch - Livestock Feedlot Operations 46. Cement Hauling - Cement Bulker

2. Back County Tour/Guide Operations 24. Sod Farm Operations 47. Gen Const Prod Hauling - Lumber/Rebar/Etc

3. Carpet & Upholstery Cleaning 25. Commercial Nursery & Horticulture Operations 48. Irrigations Systems Operations

4. Cemetery & Crematorium Operations 26. Forestry & Logging Operations Mining/ Oil & Gas Prod

5. Equipment Rental & Leasing Operations 27. AG Dealer - Fert/Chem “Custom Appln.” 50. Ores & Rock Quarry Operations

6. Public Golf Course Operations Construction 51. Coal Mining Operations

8. Recreational Parks/ Camp Operations 30. General Construction 52. Sand & Gravel Pit Operations

9. Marina Operations 31. Highway & Road Construction 53. Crude Pet & Natural Gas Prod Facilities

10. Ski Resort Operations 32. Commercial Building Construction 54. Oil & Gas Exploration & Drilling Operations

11. Snow Mobile Tour Rental Operations 33. Construction Excavation & Digging 55. Oil & Gas Field Service Operations

12. Lawn/Garden/Landscape Services 34. Residential Construction Manufacturing

13. Mobile Wash Operations 35. Water Well Drilling 60. Manufacturing Operations - General

14. Waste Disposal Facilities & Operations Transportation/ Comm 61. Concrete Prods, Brick, Block Mfg

18. Commercial Avn - Fixed Base Operations 40. Refrigerated Trailers 62. Sawmill Operations

19. Agricultural Crop Dusting & Spraying 41. Aviation - Scheduled Air Carriers 63. Recycling & Mfg Operations

Agriculture/ Forestry/Fishing 42. Railroad Operations on Rails Public Administration/Govt

20. Crops - Grain (Wheat, Corn, Barley, Hay, Etc) 43. Waste Disposal hauling - Res/Com 99. State, Local, Federal, Public Education, Dists

21. Crops - Fruits or Vegetables 44. Sand, Gravel & Aggregate Hauling

22. Farm/Ranch - Livestock Grazing Operations 45. Ready Mix Cement Hauling
Signed under penalty of perjury in the second degree
Taxpayer’s Last Name (Individual, partners, corporate or political subdivision) First Name Middle Initial

Applicant’s signature Phone Number
( )
Signatures of Other Officers Authorized to Sign Refund Checks Date (MM/DD/YY)

IV. Provide a brief description of your business and detail how the fuel is used in your business for exempt and
non-exempt use.

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*147189==39999*

V. If you have checked the special fuel box in Section II, please answer the following questions:

1. Is the fuel being placed in the tank of a vehicle with a current license plate? Yes No

2. Is there some other activity (such as operating a cement mixer) that uses fuel taken from the
same tank as the fuel that propels the vehicle on the road? Yes No
3. Is the vehicle(s) licensed for IFTA? In what Jurisdiction?

Yes No
Note: Fuel used in vehicles licensed and plated for on-road use does not qualify as exempt fuel. The only exemption is fuel used as a
power source for a qualifying exempt purpose other than powering the vehicle on the road. Also, no refunds on dyed diesel are allowed.
VI. List all the equipment and vehicles using the fuel you purchase. If additional space is required, attach a separate
sheet using the same format. You can attach your own vehicle/equipment list, if all the required information is
provided:(If fueling from bulk storage facilities - list all vehicles and equipment fueled from the fuel supply storage).
Miles Reported
Make & Type Model/ License Plate Number or Fuel Type
Equipment Use On IFTA Return
of Equipment Year I.D. Number if Not Plated Used
(Y/N)

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Information and Instructions

Gasoline, Gasohol, Aviation and Special Fuel • Special fuel is: diesel engine fuel, kerosene,
A refund may be claimed for fuel tax paid on these liquefied petroleum gas and natural gas used for
fuels purchased and used in Colorado for the following the generation of power to propel a motor vehicle
purposes: on Colorado highways. Special fuel does not
include gasoline.
1. To operate stationary engines, motor boats or Note: Refund requests for special fuel types:
vehicles on or over fixed rails. compressed natural gas, liquefied natural gas and
LPG are to be completed under the appropriate
2. Farm vehicles when used on farms and ranches, and columns. DO NOT include refund requests for
farm tractors and implements of husbandry when these fuel types under the Special Fuel column.
operated off the public roads.
• Aviation gasoline is: gasoline used as fuel for the
3. For cleaning, dyeing or any other commercial use of propulsion of non-turbo-propeller or non-jet engine
equipment or machinery not used on roads. aircraft.

4. To operate any machine owned or operated by the • Aviation jet fuel is: gasoline used as a fuel for the
United States or any of its agencies, the State of propulsion of turbo-propeller or jet engine aircraft.
Colorado or any of its agencies, any town, city, county,
city and county, or Colorado school district and any Refund Permit - Refund applicants must obtain a permit
other political subdivision of Colorado. number from the Department of Revenue before or at
the time the first refund claim is made. All claims and
5. Vehicles or construction equipment operated within the correspondence must bear the refund permit number. A
confines of highway construction projects when permit number will be canceled if the holder files no claim
actually used in the construction of such highways. for a period of 24 months.Claimants are required to notify
this office of any changes in the nature of the business
6. State licensed agricultural applicator aircraft used or address by written letter or web message. Claimants
exclusively for agricultural applications and used only are also required to notify this office and re-apply for a
on private landing facilities. Aviation fuel tax will only be new permit if there is an ownership, name, DBA or FEIN
refunded to the extent of 50 percent of tax paid. change. Permits are nontransferable.
7. Aircraft operated by scheduled air carriers or commuter Refund Claims - All claims must be made within twelve
airline operators. months after the fuel purchase. Only one claim may be
filed in a calendar quarter, (Jan.–March, or July–Sept.,
8. Fuel used for aviation purposes (items 6 and/or 7) on etc.)
which the gasoline or special fuel tax has been paid.
Refunds are not allowed on claims for less than 20 total
Completion of the Application Form gallons(except for Political Subdivisions and Government
Business Information: Provide name of the claimant, Entities).
business location address, and mailing address. If the
name of the claimant is a corporation enter it or if partners, Political Subdivisions/Government Entities -
enter partner names. Refunds will be made on all tax-paid purchases of fuel
regardless of gallon amount. The fuel must be used
You must provide a social security number or your FEIN in government vehicles in the conduct of government
number for the claimant. Indicate the type of ownership. business.
You must provide a telephone number.
Record Keeping -
Check the type of fuel for which you will be claiming a You must maintain records of your fuel usage for three
refund. Enter the fuel storage capacity of your storage years.
tanks for fuel used in your business operations.
Refund Claims for IFTA Qualified Vehicles -
• Gasoline is: a flammable liquid used primarily as Any refund request that includes fuel placed in the tank of
a fuel for the propulsion of motor vehicles, motor a vehicle whose miles are reported on an IFTA return must
boats or aircraft. answer the questions in Section V and will, upon approval,
receive a separate refund claim form for IFTA related
• Gasohol is: a minimum blend by volume of requests.
10 percent alcohol derived from agricultural
commodities and forest products, added to Mail to:
gasoline. Colorado Department of Revenue
Denver, CO 80261-0009

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