Form 3712 - Motor Fuel Tax License Application 2009 Page 2
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8Form 3712, Page 2
20. Do you hold a Federal 637 registration under section 4101 of the Internal Revenue Act?
Yes
No
If yes, enter your Federal 637 number and activity letter (attach a copy of your registration letter): _______________________
21. Has the corporation, LLC, LLP, partnership, or any officers, members,
22. Has the corporation, LLC, LLP, partnership, or any officers, members,
controlling shareholders of the corporation or owners of the business
controlling shareholders of the corporation or owners of the business had
been convicted of any felony or misdemeanor involving motor fuel or any
a motor fuel license revoked or refused for issuance or renewal in the
tax issues?
State of Michigan or another state or foreign jurisdiction?
Yes
No
Yes
No
If yes, explain:
If yes, explain:
23a. Has the corporation, LLC, LLP, partnership, or any officers,
23b. Has the corporation, LLC, LLP, partnership, or any officers,
members, controlling shareholders of the corporation or owners of the
members, controlling shareholders of the corporation or owners of the
business been licensed in another name in Michigan?
business been licensed in another state?
Yes
No
Yes
No
Account Number (FEIN, TR, ME Number):_______________________
State:______________________________
Account Number (FEIN, TR, ME):_____________________________
PART 3: STORAGE/INVENTORY
24.
Will you maintain bulk fuel storage facilities that are not part of a federally
Yes
No
If Yes
Owned?
Leased?
registered terminal or refinery?
Gasoline (including
Clear Diesel (including
Dyed Diesel (including
Aviation
Unblended Biodiesel
Unblended
Total Fuel Storage
Ethanol Blend)
Biodiesel blend)
Biodiesel blend)
Fuel
(B100)
Ethanol
in Gallons:
In Michigan
Outside Michigan
Address and storage capacity for each storage location. (Attach additional sheet(s) if necessary)
Receipts
25. From whom will you purchase fuel and which fuel types will you purchase? List below all companies by name, federal identification number,
location, and product codes, including dyed diesel. (Attach additional sheet(s) if necessary)
Name
FEIN
Location (City, State/Province, Country)
Product Code
Disbursements
26. Will you sell dyed diesel fuel for taxable purposes?
Yes
No
If yes, identify purchaser and explain:________________________________________________________________________________________
Company Name
FEIN
Address
City, State, Zip
PART 4: CARRIER INFORMATION (Pipeline or Marine Vessel moving fuel above the terminal rack.)
27. Will you be a shipper of record on one of the commercial pipelines serving the State of Michigan?
Yes
No
If yes, name of pipeline
FEIN
28. a. Will you own or operate a commercial pipeline serving Michigan?
Yes
No
If yes, operating as _______________________________.
b. Will you own or operate a marine vessel serving Michigan?
Yes
No
If yes, operating as _______________________________.
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