Form Mf-53 - Application For Motor Fuel Retailers License Page 2
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1
2State of
County of
, ss:
I,
, first being fully sworn, state that the above application, and all
statements contained therein, are true and correct, under penalty of perjury.
(Signature of Owner, Partner, Corporate Officer, or Person Authorized by Attached Power of Attorney)
(Title)
Subscribed and sworn to before me, this
day of
20
My commission expires
20
(Notary Public)
INSTRUCTIONS
1. No fee required for this license.
2. You must file a separate application for each retail location.
3. Licensed distributors or retailers providing original invoices to end users to use in applying for a
refund of the state motor fuel tax must use invoices previously approved by the state or use state
issued invoices. Attaching a copy of your invoice to this application will ensure approval of your
invoice or issuance of state invoices for your use.
4. You must report any change in ownership including a change in partners, corporate officers or
stockholders owning 5% or more of company stock within 30 days of the change.
This completed application or inquiries concerning this application should be directed to:
Kansas Department of Revenue
Customer Relations
915 SW Harrison St.
Topeka, Kansas 66612-1588
or
Phone (785) 368-8222
Fax: (785) 296-4993
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Parent category: Financial