Form Mf 201 - Application For License As A Motor Fuel Dealer Form - 2010 Page 3
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3MF 201
Rev. 7/10
Page 3
22. Do you own/lease your own tank wagons/tank tanks?
Yes
No If yes, provide quantity, vehicle serial numbers
and Ohio fuel use permit number, if applicable.
23. Provide the name, address, telephone number and account number of all banks you intend to use to remit motor fuel
taxes (attach separate sheet, if necessary).
24. Have you, any partner, member or corporation in which you or any other partner had greater than 5% interest ever had
a motor fuel dealer’s license revoked by any state, federal government or province?
Yes
No If yes, provide the state, etc., the reason for revocation, and the date of revocation.
25. List the states (including the federal government) and license number for each state in which you are currently authorized
as a motor fuel dealer/distributor (attach separate sheet, if necessary).
26. Do you operate or own any retail service stations?
Yes
No If yes, provide name and address of each location
(attach separate sheet, if necessary).
27. How many retail stations will you supply?
28. Will you be supplying home heating oil to customers? If so, list the types of home heating oil you’ll be supplying.
29. What is your estimated monthly Ohio motor fuel tax liability? $
30. Have you, any partner, member or a corporation in which you or any other partner had greater than 5% interest ever
been in bankruptcy?
Yes
No If yes, provide explanation and date(s) of bankruptcy.
31. If you are a sole proprietor, attach a copy of your most current federal income tax return. Otherwise attach a complete,
current fi nancial statement, as prepared by your accountant, to this application. A self-generated fi nancial statement is
not acceptable.
It is understood that upon approval of this application, the applicant will comply with all the laws/requirements of Ohio Revised
Code Chapter 5735. It is also understood that the applicant will be required to fi le with the Department of Taxation, a surety
bond in the amount of at least $5,000 in accordance with R.C. section 5735.03. Failure to comply with applicable law could
result in revocation of license, assessment of tax, interest and penalties and possible criminal prosecution.
Signature of dealer or offi cer of company
Title
Date
Sworn to before me and in my presence subscribed this
day of
20
.
Notary public
Return original application to the Department of Taxation, Motor Fuel Tax Compliance Unit, P.O. Box 530, Columbus,
Ohio 43216-0530. Retain copy for your fi les. Direct any questions to (855) 466-3921 or fax (614) 752-8644.
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