Service Nova Scotia and
Program Management and Corporate Services
Provincial Tax Commission
APPLICATION FOR REBATE OF GASOLINE AND DIESEL OIL TAX FOR TAX INCLUDED IN UNCOLLECTIBLE
ACCOUNTS PURSUANT TO REGULATIONS 3A OF THE REVENUE ACT REGULATIONS
Type of Business W holesaler Retailer
Note: This application to be used when gasoline or diesel oil tax was charged and debts written off on or after
June 18, 1996.
Name of Claimant
Collector’s Permit Number:
Address of Claimant:
Claimant’s Telephone Number: ( )
Period of Claim: From: Day Month Year To Day Month Year
Do you authorize any person other than an officer of your company to act on your behalf with regards to this claim ?
Yes No If yes, please complete PART B.
Authorized Person’s Name: Telephone No.: ( )
Address: Postal Code
Gasoline and Diesel Oil Tax Rates:
Please contact Servic