Application for refund of fuel excise duty
and motor vehicle account fuel levies
Transport Agency copy
Part A: Purchases
Excise Refund Customer Number
MR70
Petrol
Please tick one box only
LPG CNG
Please tick if this is your first fuel excise duty refund claim
Applicant details
Claim for quarter ending (tick one box only and insert year)
Mailing address
Email address
Tow n
Initials & surname
or company name
31 Mar
30 Jun
30 Sep
31 Dec
Opening balance/carried over from previous quarter - taken from box 3 last claim
1
TOTAL A
TOTAL B
TOTAL C
Total purchases - complete schedule on page 3 and transfer total
2
Add boxes 1 and 2 to get Total A – this is total fuel available for use
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 to get Total B – this is fuel not able to be claimed
Subtract Total B from Total A to get Total C – this is the total fuel claimed for refund
(only purchases or deliveries made within the quarter can be included in claim)
No. of litres or GJ (CNG claims only)
Part B: How was Total C fuel used
Make/model
Plate number
Litres/GJ used
(not on public roads)
Make/model VIN/chassis Litres/GJ used
Year of
manufacture
Litres/GJ usedQuantityType
Plate number
Current hubodometer reading
Litres/GJ used
Name of vessel
Expiry date
Litres/GJ used
TOTAL FUEL
USED
Total 2
Total 3
Total 4
Total 5
Total 1
TOTAL D
Important: Applicants must check that Total D is equal to Total C.
date stamp and initials
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
Print name
Phone no.
Date
( )
Commercial activity for which
the claim is being lodged
Oce use only
if there is not enough room on Part B of the form, further room is supplied on page 2,
or a schedule can be attached with all required information.
Note:
page 112/17
RUC paid to
Maritime safety no.
1. Vehicles currently
licensed in classes
A or B
5. Commercial
vessels
4. Vehicles subject to
road user charges
(vehicle = a conveyance
that transports people
or objects)
2. Unregistered
vehicles
(vehicle = a conveyance
that transports people
or objects)
3. Commercial
purposes
Specify all machinery
(not vehicles)
(include subtotals from
page 2 as applicable)
LPG applications only: Automotive pump reading
ClosedOpen
Part B: How was Total C fuel used (continued)
TOTAL FUEL
USED
Subtotal 2
Subtotal 3
Subtotal 4
Subtotal 5
Subtotal 1
(add these subtotals to
page 1 of the application)
page 212/17
Make/model
Plate number
Litres/GJ used
(not on public roads)
Make/model VIN/chassis Litres/GJ used
Year of
manufacture
Litres/GJ usedQuantityType
Plate number
Current hubodometer reading
Litres/GJ usedRUC paid to
Name of vessel
Expiry date
Litres/GJ used
Maritime safety no.
1. Vehicles currently
licensed in classes
A or B
5. Commercial
vessels
4. Vehicles subject to
road user charges
(vehicle = a conveyance
that transports people
or objects)
2. Unregistered
vehicles
(vehicle = a conveyance
that transports people
or objects)
3. Commercial
purposes
Specify all machinery
(not vehicles)
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
Name of and location of vendor Type of fuel Purchase/delivery date No. of litres
TOTAL
SCHEDULE OF PURCHASES
Carry over to Part A Purchases (No. 2)
MR70
page 312/17
Application for refund of fuel excise duty
and motor vehicle account fuel levies
Super Service Station, Gore
Example
Synergy 1000 06/12/17 36.42
NOTES FOR APPLICANT
CLAIM PROCESSING
Forward this application with your supporting documentation to:
Fuel Excise Duty
NZ Transport Agency
Private Bag 11777
Palmerston North 4442
We do not return any documents that you forward to support your application. Ensure that you take a copy of all original documents
before submitting your application.
CLAIM PERIODS
A separate claim must be completed for each quarter and for each fuel type.
Claim periods are for three month periods ending 31 March, 30 June, 30 September and 31 December. Only one claim per period per
fuel type is to be lodged.
CHANGE OF DETAILS
If you have a change in details (eg commercial activity change, farm location, farm size) phone 0800 108 809 or email fed@nzta.govt.nz
to let us know the changes.
TIME LIMITS
The claim should be lodged within 3 months after the close of the quarter.
If it is lodged after 3 months but not later than 2 years, the refund will be reduced by 10%.
If it is lodged more than 2 years after the close of the quarter the refund will be declined.
SUPPORTING DOCUMENTATION
Proof of purchase
Applications must be made on the basis of supply date. Suitable documentation showing supplier, quantity, type of fuel and date of
purchase is required to support all purchase details. Please attach copies of proof of purchase.
Documents that may be acceptable are:
a copy of the fuel purchase tax invoice or statement, or
an ocial fuel summary from the company the fuel was purchased from.
At any time during the next 7 years you may be required to provide additional information to support the claim.
PAYMENT OF CLAIM
After your refund has been approved, a direct credit refund and remittance advice will be supplied.
LEGISLATION
Legislation providing for the refund of excise duty on fuels is contained in section 5 of the Land Transport Management (Apportionment
and Refund of Excise Duty and Excise-Equivalent Duty) Regulations 2004. Refunds of ACC levies are provided by the Injury Prevention,
Rehabilitation and Compensation (Refund of Fuel Levy) Regulations 2003.
Refund rates may vary due to Government Regulations. The actual rate used to calculate your refund will be shown on the remittance
advice returned with your refund (GST inclusive).
ACC MOTOR VEHICLE ACCOUNT LEVY
ACC motor vehicle account levy refund is included in the refund payment where applicable.
QUERIES
Any queries concerning refunds of fuel excise duty contact the above address, phone 0800 108 809 or email fed@nzta.govt.nz.
NZ Transport Agency Factsheet 14 Excise duty: Who can get refunds and how is available from Transport Agency oces, or online at
www.nzta.govt.nz.
INFORMATION REQUIREMENTS
The particulars specified will be stored and/or form part of the Excise Duty Refund Register maintained by the Transport Agency and
may be used to amend information on other registers held by the Transport Agency.
The personal information requested on this form is collected for the purposes of section 5 of the Land Transport Management
(Apportionment and Refund of Excise Duty and Excise-Equivalent Duty) Regulations 2004 and the Injury Prevention, Rehabilitation and
Compensation (Refund of Fuel Levy) Regulations 2003.
The application will not be accepted unless all the required information is provided.
You are entitled to, and may request correction of, any readily retrievable information about you held by the Transport Agency, by
writing to the NZTransport Agency, Private Bag 11777, Palmerston North 4442 or email fed@nzta.govt.nz.
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