Form Tr-680 - Promptax-Repaid Sales Tax On Motor Fuel And Diesel Motor Fuel Enrollment Application - Nys Tax Department

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New York State Department of Taxation and Finance
PrompTax — Prepaid Sales Tax on Motor Fuel and Diesel Motor Fuel
Enrollment Application
You must complete sections I, III, and VI of this application. Section IV must be completed only if you are selecting the
ACH Debit option. Mandatory participants must enroll within 40 days of the postmark of the official notification letter.
Failure to enroll within 40 days may result in the imposition of a penalty.
Note: Required fields are indicated by an asterisk (
).
*
I. Enrollment data
*
Taxpayer ID:
DBA company name:
(please print)
*
Legal company name:
Mailing address:
City:
State/Province:
Country:
ZIP code:
Please indicate below the individual designated as the taxpayer’s primary contact for the PrompTax Prepaid Sales Tax
on Motor Fuel and Diesel Motor Fuel Program. This individual will receive all material related to PrompTax participation,
including access code, confidential password, forms, and payment advices. Do not designate a paid preparer as a primary
contact person. The taxpayer’s primary contact person must be a member of its organization. Please make entries in all the
fields below.
*
Primary contact person:
(please print)
*
Mailing address:
*
City:
*
State/Province:
*
Country:
*
ZIP code:
*
Telephone number: (
)
Fax number: (
)
Email address:
TR-680 (5/05)
(continued)

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