Form 04-407 - Qualified Dealer License Application

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Department of Revenue
Alaska Department of Revenue
Voice: 907.269.6620
Fax: 269.6644
Tax Division
Qualified Dealer License Application
PO Box 110420
E-Mail:
15 AAC 40.600
Tax_Motor_Fuel@revenue.state.ak.us
Juneau, AK 99811-0420
LICENSEE INFORMATION
Taxpayer Name
Federal EIN
Business Name
Entity Type:
Corporation
Partnership*
Individual*
LLC*
* Attach list of owners, their addresses, and phone numbers
MAILING ADDRESS
PO Box or Street Address
Telephone Number
Fax Number
City
State
Zip Code
Contact Person
E-Mail Address
LICENSE TYPE
Refines, blends, imports, manufactures, and/or produces motor fuel
Check the appropriate box:
Sells at least 50 percent of fuel to another party for resale and/or for residential heating purposes.
Sells at least 50 percent of fuel to another party for use in jet propulsion aircraft.
AFFIDAVIT OF ESTIMATED TAX
(If at any time during the year these estimates are lower than actual gallons subject to tax, you must file a
corrected affidavit and comply with any additional security requirements. The corrected affidavit and additional tax security is due 30 days after you
have knowledge of the underestimate.)
Estimated Monthly Sales (Gallons)
Tax Rates
Tax Liability
Jet Fuel
x
$0.032
=
0.00
Aviation Gas
$0.047
x
=
0.00
Marine: diesel & gasoline
$0.05
x
=
0.00
Highway: diesel, gasoline & gasohol
$0.08
x
=
0.00
Highway: gasohol special rate
$0.02
x
=
0.00
0.00
Total Estimated Maximum Monthly Tax Liability (Add amounts in this column) ……………………………………
Your estimated maximum monthly tax liability must be secured either by a bond, cash, letter of credit, or certificate of deposit from an Alaska bank.
Check one:
Bond in an amount equal to twice the average monthly motor fuel tax remittance but not less than $5,000.
Cash, letter of credit or certificate of deposit from an Alaska bank in an amount equal to twice the average monthly motor fuel tax remittance but
not less then $5,000.
Location of Storage Facility
Capacity
Legal Description
QUALIFIED DEALER REPORTS
Check here if you would like to receive hard copy qualified dealer reports.
Note that an up-to-date listing is available at all times on our website at
I certify that an accurate record will be kept of all purchases, sales and uses of fuel, that the required monthly returns will be filed and tax will be paid on or before the last
day of the following calendar month. Under penalty of perjury, I declare that this application and any attachments have been examined by me and to the best of my
knowledge and belief are true, correct, and complete.
Signature
Printed Name
Date
NOTARY
Subscribed and sworn to or affirmed before me at _____________ in the State of __________ this _______ day of ________________, ________.
CITY
Signature: ________________________________________ Notary Public for: _____________ My Commission Expires: _____________
DEPT USE
Examined By:
License Number Issued:
Approved
Disapproved
Form 04-407 Webform (Rev 03/03)

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