Form Reg-5mf - Application For Motor Vehicle Fuels Tax Or Petroleum Products Gross Earnings Tax - Connecticut Department Of Revenue Services
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2REG-5MF
STATE OF CONNECTICUT
DO NOT WRITE IN THIS BLOCK
DEPARTMENT OF REVENUE SERVICES
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APPLICATION FOR
25 SIGOURNEY STREET
MOTOR VEHICLE FUELS TAX OR
HARTFORD CT 06106-5032
PETROLEUM PRODUCTS GROSS EARNINGS TAX
(Rev. 06/00)
PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS
APPLICATION. PRINT CLEARLY IN INK OR TYPE ALL INFORMATION REQUESTED.
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1. Reason for applying
:
“Tax Paid” Gasoline Distributor (Purchase Tax Paid)
Motor Vehicle Fuels Distributor (Purchase Tax Free)
FOR DRS
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~
USE ONLY
Motor Vehicle Fuels Exporter
Diesel Fuel Distributor
Petroleum Products Gross Earnings
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TAX REG
TR
AD
Diesel Fuel Exporter
Gasohol Distributor
Aviation Fuel Dealer
Heating Oil Declaration Distributor (Complete front and back)
2. OWNER’S NAME, PARTNERSHIP NAME, CORPORATE NAME OR LLC NAME
FEDERAL EMPLOYER ID NUMBER
00
3. TRADE NAME OR REGISTERED NAME (if different from Line 2 above)
SOCIAL SECURITY NUMBER
00
1 2 3 4 5
1 2 3 4 5
4. PHYSICAL LOCATION OF THIS BUSINESS (a P.O. Box is not acceptable)
ZIP + 4
TELEPHONE NUMBER
1 2 3 4 5
00
1 2 3 4 5
(
)
1 2 3 4 5
1 2 3 4 5
5. BUSINESS MAILING ADDRESS (if different from Line 4 above)
ZIP + 4
1 2 3 4 5
00
1 2 3 4 5
1 2 3 4 5
~ OWNER ~ PARTNER ~ CORPORATE OFFICER ~ LLC MEMBER
6a. NAME OF
SOCIAL SECURITY NUMBER
00
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
HOME ADDRESS Number and Street
City or Town
State
ZIP + 4
1 2 3 4 5
00
1 2 3 4 5
~ PARTNER ~ CORPORATE OFFICER ~ LLC MEMBER
6b. NAME OF
SOCIAL SECURITY NUMBER
00
1 2 3 4 5
1 2 3 4 5
HOME ADDRESS Number and Street
City or Town
State
ZIP + 4
1 2 3 4 5
00
1 2 3 4 5
1 2 3 4 5
~ PARTNER ~ CORPORATE OFFICER ~ LLC MEMBER
6c. NAME OF
SOCIAL SECURITY NUMBER
00
1 2 3 4 5
1 2 3 4 5
HOME ADDRESS Number and Street
City or Town
State
ZIP + 4
1 2 3 4 5
00
1 2 3 4 5
1 2 3 4 5
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7.
TYPE OF OWNERSHIP (if other, attach explanation)
INDIVIDUAL
PARTNERSHIP
CORPORATION
LLC
OTHER
7a. IF A CORPORATION OR AN LLC, LIST STATE OF INCORPORATION _________________________________________________________________
8.
ARE YOU CURRENTLY REGISTERED WITH THE CONNECTICUT DEPARTMENT OF REVENUE SERVICES?
~ YES ~ NO
If YES, enter Connecticut tax registration number:
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TAX TYPES CURRENTLY REGISTERED FOR:
SALES TAX
CORPORATION TAX
MOTOR CARRIER ROAD TAX
OTHER
9.
IF YOU ARE THE SUCCESSOR TO A REGISTERED DISTRIBUTOR, ENTER:
PRIOR DISTRIBUTOR’S NAME ________________________________________________________________________________________________________________
PRIOR DISTRIBUTOR’S ADDRESS _____________________________________________________________________________________________________________
10. LIST ALL SUPPLIERS OF MOTOR VEHICLE FUEL AND HOME HEATING OIL (attach additional sheets, if necessary)
NAME
ADDRESS
11. IF APPLYING FOR A MOTOR VEHICLE FUELS EXPORTER LICENSE, ENTER:
DISTRIBUTOR’S LICENSE NUMBER IN STATE OF DESTINATION ______________________________________________________
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(If YES, indicate location and capacity of storage on an attached list.)
DO YOU MAINTAIN FUEL STORAGE TANKS IN CONNECTICUT?
YES
NO
12. IF IMPORTING DIESEL FUEL OR MOTOR VEHICLE FUEL INTO CONNECTICUT,
13. NUMBER OF GALLONS OF MOTOR VEHICLE FUEL OR DIESEL FUEL
INDICATE THE ANTICIPATED POINT OF ENTRY AND METHOD OF DELIVERY.
YOU EXPECT TO SELL EACH MONTH IN CONNECTICUT.
I declare under the penalty of false statement that I have examined this application, REG-5MF, and, to the best of my knowledge and belief it is true, complete
and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars, or both.)
SIGNATURE
TITLE
DATE
DO NOT WRITE BELOW THIS LINE - FOR DEPARTMENT USE ONLY
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
TAX
REC.
TRANS.
REGISTRATION DATE
NAICS CODE
TYPE ORG.
STATE
LEGAL DATE
TOTAL SUBMITTED
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
00
10
/
/
/
/
00
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
TAX
REC.
TRANS.
REGISTRATION DATE
START DATE
TOWN
SOURCE
FILE CODE
10
/
/
/
/
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
BOND DATE
BOND AMOUNT
STATE DESTINATION
EXPORTER’S LICENSE NUMBER
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
/
/
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
EFFECTIVE DATE
APPROVED BY:
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