New York State Department of Taxation and Finance
                                                                                                                                                            FT-500
                      Application for Refund of                                                                                                             (9/11)
                      Sales Tax Paid on Petroleum Products                                                           For office use only
                      Tax Law — Articles 28 and 29                                             Total             $                                          Date
                                                                                               Audited by
                                                                                               Approved by
                                                                                               Approved by
                                                                                               Approved by
    Name1.                                                                                     2. Period covered by claim (date(s) of purchase)(mm/dd/yyyy)

    3.Street address                                                                           4.  Telephone number
                                                                                                  (    )
    City5.                                County                             State ZIP code    6.  Employer identification number (EIN)
                                                                                                                   — 
                                                                                               7.  Total amount of refund claimed
Note: Complete this application in full, including the Schedule of motor fuel and diesel motor 
        fuel purchases on page 3. This form may not be used to claim a refund of the prepaid
        sales tax (see instructions).

8. Fuel was used      (mark an  Xin applicable box; see instructions)

      A —    by an exempt organization  ............................................................................................................................................

             If marked, enter 6-digit exempt organization number and attach a copy of Form ST-119,
             Exempt Organization Certificate  ..............................................................................................................

      B —    by a qualified Indian nation or tribe ................................................................................................................................

             If marked, enter 6-digit exempt organization number and attach a copy of Form ST-119,
             Exempt Organization Certificate  ..............................................................................................................

      C —    in farm production or in a commercial horse boarding operation  .................................................................................

      D —    by a qualified empire zone enterprise (QEZE)  ...............................................................................................................

             Mark an  Xin the box next to the applicable employment test worksheet and attach the appropriate form to the 
             application.

                AU-12.1, Employment Test for Businesses Certified by Empire State Development (ESD) Before April 1, 2005

                AU-12.2, Employment Test for Businesses Certified by Empire State Development (ESD) On or After April 1, 2005, 
                and Before April 1, 2009

                AU-12.3, Employment Test for Businesses Certified by Empire State Development (ESD) On or After April 1, 2009

      E —    by an omnibus carrier or vessel operator in local transit service  ..................................................................................

      F —    for residential purposes  .................................................................................................................................................

      G —    by a qualified Indian  ......................................................................................................................................................

             If marked, enter both of the following: • qualifying tribe or nation ...............................

                                                    • qualifying reservation ....................................

      H —    by manufacturers, processors, generators, assemblers, refiners, miners, and extractors  ...........................................

      I —    other  ..............................................................................................................................................................................

             If marked, enter explanation  ..................................
                                                                                                                           (continued on page 2)

Page 2 of 3     FT-500 (9/11)

9. Mark an  Xin this box if you are filing this sales tax refund form together with a refund form for motor/diesel motor fuel tax
   or petroleum business tax for the same period. Attach invoices or other information as required by all forms and mail all
   forms in one envelope.  ...........................................................................................................................................................

Certification: I,                                                  , the applicant named above, or partner, officer, or other authorized 
representative of such applicant, do hereby: 
•  make application for refund of tax, pursuant to the New York State Tax Law; and 
•  certify that the above statements, and any documents provided to substantiate the refund claimed, are true, complete and 
  correct and that no material information has been omitted; and 
•  certify that all of the tax for which this claim is filed has been paid, and no portion has been previously credited or refunded 
  to the applicant by any person required to collect tax; or, if the claim for refund is made by a person required to collect tax, 
  that the amount claimed has not previously been refunded to the appropriate purchaser; and 
•  certify that no amount claimed has previously been subject to a credit or refund; and 
•  make these statements with the knowledge that willfully providing false or fraudulent information with this document with 
  the intent to evade tax may constitute a felony or other crime under New York State Law, punishable by a substantial fine 
  and a possible jail sentence; and 
•  understand that the Tax Department is authorized to investigate the validity of the refund claimed and the accuracy of any 
  information provided with this claim.
                  Signature of authorized person                             Official title
Authorized
   person         E-mail address of authorized person                                      Telephone number              Date
                                                                                           (          )
   Paid        Firm’s name (or yours if self-employed)                                     Firm’s EIN                    Preparer’s PTIN or SSN
preparer   Signature of individual preparing this return          Address                    City                        State ZIP code
   use
   only        E-mail address of individual preparing this return         Telephone number            Preparer’s NYTPRIN Date
(see instr.)                                                              ( )

         of 3

                Page 3                                                                                      H
                                                                                                              Sales tax
        (9/11)                                                                                                                                                    refund claimed                    (dollars and cents)

                FT-500                                                                                                                                                                               

                                                                                                            G 
                                                                                                              Total 
                                                                                                                                                                  sales tax                         (on invoice)

                                                                                                            F                                                                                                            (enter amount on page 1, line 7) 
                                                                                                                                                                  gallons 
                                                                                                              Number of 
                                                                                                                                                                                                                         
                                                                                                            E 
                                                                                                              Type of                                             product*                          (see Pub 902)

                                                                                                            D                                                                                                           
                                                                                                              Invoice                                             number                                                                                   Total amount of refund claimed

                                                                                                            C                                                                                                           

                                                                                                              Delivery location                  (city and county)

                                                      Schedule of motor fuel and diesel motor fuel purchases

                                                                                                            B                                                                                                           

                                                                                                              Seller’s name 

                                                                                                            A 
                                                                                                              Date of                                             purchase