Form Boe-400-Tpa (S1f) - Trading Partner Agreement For Boe Motor Fuels Electronic Filing Program Page 3

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BOE-400-TPA (S2F) REV. 2 (5-07)

The password must be ten alphanumeric characters (any combination of 10 letters and numbers) in length with no special characters or

spaces. Please enter the password in the space provided below. Use upper case for letters.

(Designate the number zero as “Ø”, to distinguish it from the letter “O”.)

15. Contacts: For the purposes of this agreement, the BOE’s contact for the Motor Fuels Electronic Filing Program will be the Fuel Taxes

Division.

Following are the names, telephone and FAX numbers, and e-mail addresses of the Taxpayer’s contacts for technical information or

questions on transmissions under this program, and for questions regarding the tax information being submitted. Each contact will be

provided a User ID and Password for online access to the BOE Motor Fuels Electronic Filing System.

TAXPAYER’S E-FILING TECHNICAL CONTACT PERSON:

NAME

TELEPHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

(

)

(

)

TAXPAYER’S EXCISE TAX INFORMATION CONTACT PERSON:

NAME

TELEPHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

(

)

(

)

Note: Taxpayers wishing to identify additional contact persons should attach a list containing the information requested above for each

additional contact person.

16. Electronic Return Originator (ERO) Information: Please complete the following information to appoint a third-party ERO to

electronically file your tax forms and receive all electronically generated messages and acknowledgments concerning the status of the

electronic filing:

ERO NAME

MAILING ADDRESS (city, state, zip code)

17. Changes in the Information Contained in this Agreement: The Taxpayer must notify the BOE in writing of any changes in the

information contained in this agreement within thirty (30) days of the change occurring. A change of Authorized Signer in item 19

requires a new Trading Partner Agreement be submitted.

18. Certification of Authorized Signer: Under penalty of perjury, I declare that I have examined this agreement and any accompanying

information, and, to the best of my knowledge and belief, it is true, correct, and complete. The Taxpayer will comply with all the

provisions of the E-Filing Guide and related publications, including fraud prevention and detection guidelines, for all years of

participation. I understand that noncompliance may result in the Taxpayer no longer being allowed to participate in the program. I am

authorized to make and sign this statement on behalf of the Taxpayer.

19. Authorized Signatures:

A. Taxpayer

NAME OF TAXPAYER

NAME OF TAXPAYER’S AUTHORIZED REPRESENTATIVE AND TITLE (please print)

SIGNATURE OF TAXPAYERS’S AUTHORIZED REPRESENTATIVE (if the authorized representative is not an owner, officer or employee of the taxpayer, attach a Power of Attorney)

DATE SIGNED

MAILING ADDRESS (city, state, zip code)

TELEPHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

(

)

(

)

Clear