Form 72A078 is the Kentucky Department of Revenue Statement of Claim for Accountable Loss of Motor Fuel. It is used by licensed gasoline and special fuel dealers to request approval for a claim involving the loss or destruction of motor fuel under qualifying circumstances. The form allows dealers to report details about the fuel loss, including the date, location, storage type, amount of fuel affected, evidence supporting the claim, and the circumstances that caused the loss.
An accountable loss may involve situations such as a wrecked transportation conveyance, explosion, fire, flood, other casualty loss, or contaminated fuel that is returned to storage. The loss must be reported within 30 days after discovery and supported by documentation that verifies the claim.
The form collects information from the dealer, including gasoline and special fuel license numbers, gallons claimed, storage details, loss explanation, supporting evidence, and certification from an authorized officer. Completing the form accurately helps the Kentucky Department of Revenue determine whether the reported loss qualifies for approval.
How To File Form 72A078
Form 72A078 must be filed within 30 days from the date of loss. The claim must be submitted in triplicate and should be typed or printed clearly.
Mail the completed claim with supporting documentation to:
Motor Fuels Tax Compliance Section
Department of Revenue
P.O. Box 1303
Frankfort, Kentucky
Before completing the form, gather:
- Dealer business information.
- Gasoline and special fuels dealer license numbers.
- Amount of gasoline and special fuel gallons claimed.
- Loss date and location details.
- Storage information.
- Inventory records.
- Invoices, delivery tickets, and other supporting records.
- Police, fire department, or insurance reports if applicable.
The department instructions state that supporting evidence may include reports from police, fire departments, insurance companies, inventory records, purchase and sales invoices, credit invoices for contaminated product returned to terminal storage, and delivery tickets. Copies of relevant records should be attached.
How To Complete Form 72A078
Dealer Information
Name And Address Of Dealer
Enter the legal name and complete address of the dealer submitting the accountable loss claim.
Phone Number
Provide the dealer’s contact telephone number.
Contact Person
Enter the name of the person the department should contact regarding the claim.
Gasoline Dealer’s License Number
Enter the gasoline dealer license number associated with the claim.
Number Of Gasoline Gallons Claimed
Enter the number of gasoline gallons included in the loss claim.
Special Fuels Dealer’s License Number
Enter the special fuels dealer license number associated with the claim.
Number Of Special Fuels Gallons Claimed
Enter the number of special fuel gallons included in the claim.
Loss Details
Item 1: Date Of Loss
Exact Date Of Loss
Enter the month, day, and year when the loss occurred. If the exact date is unknown, enter the date the loss was discovered and explain how it was discovered.
Item 2: Type Of Storage
Storage Type Where Motor Fuel Was Lost
Select the type of storage or facility involved in the loss:
- Transport truck.
- Bulk plant.
- Service station.
- Other.
If selecting Other, describe the type of storage involved.
Item 3: Location Of Loss
Location Where Loss Occurred
Provide the exact location where the loss occurred, including the numbered street or highway and Kentucky city. If the loss occurred in a rural area, provide the nearest city or post office. If the loss occurred during transportation, include the highway number and distance from the nearest city or post office.
Item 4: Method Used To Determine Amount Of Loss
Loss Calculation Method
Explain how the amount of fuel lost was calculated. Include details such as inventory amounts, fuel added or removed, meter readings, and the amount remaining when the loss occurred.
The department provides an example method involving a tank inventory, fuel usage records, and the amount remaining after a fire or other loss event.
Item 5: Supporting Evidence
Evidence Available To Support Loss
List the documents and records available to prove the fuel loss. Examples include police reports, fire reports, insurance reports, inventory records, invoices, credit invoices for contaminated fuel returned to terminal storage, and delivery tickets.
Item 6: Storage Tank Size
Size Of Storage Tank(s)
Enter the capacity of the tank or tanks from which the motor fuel was lost.
Item 7: Contaminated Fuel Information
Gallons Of Contaminated Fuel Returned To Terminal Storage
If the loss resulted from contamination, enter the number of gallons of motor fuel that were returned to terminal storage.
Terminal Storage Operator Name And Address
Provide the name and address of the terminal storage operator where contaminated fuel was returned.
Item 8: Description Of Loss
Type Of Loss And Description Of Circumstances
Identify the type of loss, such as fire, flood, or another event, and briefly explain how the loss happened.
Claim Certification
Certification Statement
The claimant certifies that they have reviewed the claim and that, to the best of their knowledge and belief, the information provided is true, correct, and valid.
Signature Of Claimant
The authorized claimant must sign the form.
Print Name
Enter the printed name of the person signing the claim.
Title
Provide the signer’s title or position.
Date
Enter the date the claim is signed.
Department Use Only
Gasoline Gallons Approved
This section is completed by the Department of Revenue to record the approved gasoline gallons. The approved amount is attached to Form 72A089 for claiming purposes.
Special Fuels Gallons Approved
This section is completed by the department to record approved special fuel gallons. The approved amount is attached to Form 72A138 for claiming purposes.
Signature And Date
Department personnel complete the approval signature and date fields.
Final Review Before Filing
Before submitting Form 72A078, confirm that:
- The claim is filed within 30 days of the loss.
- Dealer name and contact information are complete.
- Gasoline and special fuel license numbers are correct.
- Gallons claimed are accurately reported.
- The loss date and location are clearly explained.
- The storage type is identified.
- The method used to calculate the loss is documented.
- Supporting evidence is attached.
- Tank capacity information is included.
- Contamination details are provided if applicable.
- The type and cause of loss are clearly described.
- The claimant signs and dates the form.
- Three copies of the claim and documentation are submitted.
A complete and well-supported Form 72A078 helps the Kentucky Department of Revenue evaluate an accountable motor fuel loss claim and determine whether the reported loss qualifies for approval.