Indiana > Statewide > Department Of Revenue > Fuel And Environmental > Bonds And Licensing
Fuel Tax Application FT-1 - Indiana
| Fuel Tax Application Form. This is a Indiana form and can be used in Bonds And Licensing Fuel And Environmental Department Of Revenue Statewide . |
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Fuel Tax Application Form Indiana Department of Revenue Fuel Tax Section August 2005 1 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Revenue Fuel Tax License Application FT-1 State Form 46297 (R6/01-06) This application must be accompanied by a completed Fuel Tax Surety Bond, Irrevocable Standby Letter of Credit (subject to Departmental format) or Cash Bond, and a current financial statement or beginning balance sheet, if applicable. (Please print legibly or type the information on this application) License #_______________ Effective Date ___________ SECTION A: TAXPAYER INFORMATION Contact the Department at (317) 615-2625 for more information regarding this application. 1. Owner name, legal partnership name, corporate name, or other entity name 2. Federal Identification Number (FEIN) 3. Business Trade Name or D/B/A 4. Name of Contact Person (Owner, Partner, or Corporate Officer) 5. Business Location (P.O. Box cannot be used as a business location address) City 6. Mailing address City 8. Fax Number State Zip 9. E-Mail Address County State Zip County 7. Business Location Telephone Number ( ) ( ) Partnership Other C. State of Commercial Domicile Month Day Year 10. If your business is currently registered for any Indiana tax under this ownership, enter your Taxpayer Identification Number (TID): 11. Check the type of organization of this business Sole Proprietor Corporation Fed. Govt. LLC LLP 12. All Corporations must answer the following questions: A. State of Incorporation B. Date of Incorporation Other Govt. NAICS Code: # D. If not incorporated in Indiana, enter the date authorized to do business in Indiana. E. Accounting period year ending date Month Day Year Month Day 13. Owner, Partners or Officers (Attach additional sheets if necessary) Social Security Number Last Name, First Name, MI Title Street Address City State Zip 14. License Type - Place an "X" in the box next to the license type(s) for which you are applying. Terminal Operator Fee Amt $300.00 Exporter Fee Amt $200.00 Gasoline Distributor Fee Amt $100.00 15. Reason License Needed New Business Purchase of Existing Business Purchased from whom ______________________ Other ________________ Supplier Fee Amt $500.00 Transporter Fee Amt $50.00 Oil Inspection Distributor Fee Amt $100.00 Permissive Supplier Fee Amt $50.00 Blender No Fee Required Dyed Fuel User No Fee Required Aviation Fuel Dealer Fee Amt $15.00 Eligible Purchaser No Fee Required Marina Fuel Dealer Fee Amt $15.00 Importer Fee Amt $200.00 Petroleum Severance No Fee Required Gasohol Blender No Fee Required 2 American LegalNet, Inc. www.FormsWorkflow.com SECTION B: SPECIAL FUEL SUPPLIER ($ 500.00 Registration Fee) When applying for a Special Fuel Supplier's License, you must also complete Section Q of this application. Your License will not be processed if Section Q is not completed. 1. Indiana Terminal Location(s) Total Terminal Terminal Number of If tanks are leased Address, City, State, Zip Code Storage Capacity Code Storage Tanks Name and Address of Lessee Taxable Special Fuel (#1 Diesel Fuel, #2 Diesel Fuel, and Biodiesel) 2. Annual Estimated Taxable Gallons Nontaxable Special Fuel (Dyed Diesel Fuel and Bio) 3. To calculate bond amount:Total Annual Estimated Taxable Gallons ÷ 6 × $.16 = Bond Amount Required (The bond amount must be in an amount equal to at least 2 months liability, but not less than $2,000.00.) $ .00 SECTION C: SPECIAL FUEL PERMISSIVE SUPPLIER ($ 50.00 Registration Fee) When applying for a Special Fuel Permissive Supplier's License, you must also complete Section Q of this application. Your License will not be processed if Section Q is not completed. 1. Terminal Location(s) Terminal If tanks are leased Number of Total Terminal Address, City, State, Zip Code Code Name and Address of Lessee Storage Tanks Storage Capacity Taxable Special Fuel (#1 Diesel Fuel, #2 Diesel Fuel, and Biodiesel) 2. Annual Estimated Taxable Gallons Nontaxable Special Fuel (Dyed Diesel Fuel and Bio) 3. To calculate bond amount: Total Annual Estimated Taxable Gallons ÷ 6 × $.16 = Bond Amount Required (The bond amount must be in an amount equal to at least 2 months liability, but not less than $2,000.00.) $ .00 SECTION D: SPECIAL FUEL TERMINAL OPERATOR ($ 300.00 Registration Fee) 1. Indiana Terminal Location(s) Address, City, State, Zip Code Terminal Code Number of Storage Tanks If tanks are leased Name and Address of Lessee Total Terminal Storage Capacity 2. A bond in the amount of $2000.00 is required for a Terminal Operator's License. $ 2000.00 SECTION E: SPECIAL FUEL IMPORTER ($ 200.00 Registration Fee) 1. List the states from which you plan to import fuel. A. B. C. D. Nontaxable Special Fuel (Dyed Diesel Fuel and Bio) Taxable Special Fuel (#1 Diesel Fuel, #2 Diesel Fuel, and Biodiesel) 2. Annual Estimated Taxable Gallons 3. To calculate bond amount:Total Annual Estimated Taxable Gallons ÷ 6 × $.16 = Bond Amount Required (The bond amount must be in an amount equal to at least 2 months liability, but not less than $2,000.00.) 3 $ .00 American LegalNet, Inc. www.FormsWorkflow.com SECTION F: SPECIAL FUEL EXPORTER ($ 200.00 Registration Fee) 1. List the states to which you plan to export fuel. A. B. C. D. E. F. 2. You must also submit, with this application, a copy of the license(s) from each of the destination jurisdictions listed above. 3. A Bond in the amount of $2,000.00 is required for an Exporter's License. $ 2000.00 SECTION G: SPECIAL FUEL TRANSPORTER ($ 50.00 Registration Fee) 1. Do you transport fuel in vehicles with a capacity greater than 5,400 gallons? YES / NO 2. Do you transport fuel in vehicles with a capacity of 5,400 gallons or less? YES / NO If Yes, how many?______________________ If Yes, how many?______________________ 3. Do you transport fuel by another manner other than truck? YES / NO If yes, indicate the method of transport: ____ Barge ____ Pipeline 4. A Bond in the amount of $2,000.00 is required for a Transporter's License. $ 2000.00 SECTION H: SPECIAL FUEL BLENDER (No Fee Required) Blender 1. Do you blend or plan to blend non-taxable fuels with taxable special fuels? 2. What fuel types do you blend? 3. List the location(s) where you blend fuel and the storage capacity of the tanks. Location - City, State, Zip Tank Capacity YES / NO 4. Estimate the total number of taxable gallons to be blended each calendar year. gallons No bond is required for a Blender's License. SECTION I: DYED FUEL USER (No Fee Required) Dyed Fuel User
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