Form Mf 100a - Fuel Tax License Application

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SD EForm - 0824
Department of Revenue & Regulation
Division of Motor Vehicles - Fuel Tax License Application
Return signed application to: Division of Motor Vehicles, Fuel Tax Licensing, 445 East Capitol Ave, Pierre SD 57501-3100
Please print in black ink or type. Do not write in shaded areas.
License Number issued:
Date Issued:
County Code:
Taxpayer Business Information
Instructions: All of the following blanks must be completed for all license applications. A post office box number is not an acceptable address
for your physical location; you must furnish the street address or rural route number. A post office box number is an acceptable mailing
address. The information below applies to the license applicant only. Reporting services or accounting firms see accounting section.
Owner, Partner or Corporation Name
Doing Business As Name (DBA) if different than noted above
Federal EIN Number
Business Phone Number
Fax Number
Physical Location (street address)
Mailing Location (if different than physical location)
If you have a separate address within your company that you prefer your tax return information be forwarded to, or if you wish the
information be sent to the attention of, please provide this information.
Attention of
Tax Return Mailing Address if different than above (street)
Phone Number
Accounting Information
Reporting Services or Accounting Firms: If you wish to utilize a firm to complete your tax returns please complete a Department of Revenue
& Regulation power of attorney form. Once this is completed and returned, all tax returns and any notices will be mailed to the firm’s address.
Ownership Type
Check one:
Single ownership
Informal partnership (verbal agreement between partners)
Formal Partnership (written agreement between partners)
Corporation: State of incorporation
Date of incorporation
If not South Dakota, indicate date of registration with South Dakota Secretary of State
Limited liability company
Other (List)
If you have questions concerning this application please call 605-773-5335.
MF 100A 07-03


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