Form Mf 100a - Fuel Tax License Application Page 4
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MK – Marketer: Sells fuel products in South Dakota as a wholesale distributor or retail dealer. A separate license is required for each
business located within the state. Please list each location below and your sales tax license number. Attach additional sheets if necessary.
1.
Name
Physical Address
City
State
Zip
Sales Tax License #
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
2.
Name
Physical Address
City
State
Zip
Sales Tax License #
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
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BK – Bulk plant operator: Operates a fuel storage facility in South Dakota (other than a terminal). Check the type of transportation used
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when delivering fuel FROM your plant.
Tankwagon
Transport (over 4,200 gallons)
Both
Please list your bulk plant locations, attach additional sheets if necessary.
1.
Name
Physical Address
City
State
Zip
Sales Tax License #
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
2.
Name
Physical Address
City
State
Zip
Sales Tax License #
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
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!
TM - Terminal Operator: Person who by ownership or contractual agreement is responsible for the operation of a terminal in South
Dakota. Please list terminal locations and your Internal Revenue Service control number. Attach additional sheets if necessary.
1.
Name
Physical Address
City
State
Zip
IRS Control #
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
2.
Name
Physical Address
City
State
Zip
IRS Control#
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
Important Notice - Please Read
Please complete this form in its entirety. Failure to provide the requested information is grounds for license denial. If the applicant
is a corporation, or if the applicant is a limited liability company or trust, the undersigned acknowledge and agree that they are personally
liable for filing returns and payment of taxes resulting from the operation of the company or trust. As provided in Section 7(b) of the
Federal Privacy Act of 1974, Public Law 93-579, you are informed that the social security number is a mandatory request pursuant to
SDCL 10-47B-71 and that it will be used as an identification number for file control and record keeping purposes and for possible cross-
checking with the Internal Revenue Service.
THIS APPLICATION MUST BE SIGNED by the owner, by all partners or in case of corporation, an executive officer. An authorized
person may sign for a partnership or a corporation if proof of authorization is attached to the application. Attach additional sheets for
signatures if necessary. A new form must be completed when any changes occur in owners, partners or corporate officers.
I hereby certify, as owner/operator of this business that all information provided is true and correct to the best of my knowledge
and belief. Permission is also, hereby, granted to the Department of Revenue & Regulation to release the status of this license (either
active, canceled or in arrears) to affected parties.
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Parent category: Financial