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Form Mf-48 - Application To Report And Pay Lp-Gas Tax On Mileage Basis And For Annual Mileage Permit And Decal 2004

KANSAS DEPARTMENT OF REVENUE

CUSTOMER RELATIONS

915 SW HARRISON ST.

TOPEKA, KANSAS 66625-8000

Phone Number: (785) 368-8222

Fax: (785) 296-4993

APPLICATION TO REPORT AND PAY LP-GAS TAX ON MILEAGE BASIS

AND FOR ANNUAL MILEAGE PERMIT AND DECAL

LP DEALER OR

USER LICENSE NO. ____________________

NAME ____________________________________________________________________________________________________

ADDRESS _________________________________________________________________________________________________

APPLICATION DATE _____________________________

DAYTIME TELEPHONE __________________________________

FAX NUMBER

FEDERAL EMPLOYERS’ INDENTIFICATION NUMBER (FEIN) ___________________________________________________

VEHICLES:

YEAR

MAKE

MOTOR OR

VEHICLE

ESTIMATED ODEMTOER

OFFICE

INDENTIFICATION NO.

WEIGHT

READING as of January 1, 20___

USE

Applicant hereby states that the above application, and all statements contained therein, are true and correct.

________________________________________________

Signature of owner, partner or corporate officer (Circle one)

________________________________________________

Social Security Number

SEE REVERSE SIDE FOR SCHEDULE

MF-48

(Rev. 4/04)

Form Mf-48 - Application To Report And Pay Lp-Gas Tax On Mileage Basis And For Annual Mileage Permit And Decal 2004