Form 3712 - Motor Fuel Tax License Application 2009 Page 4

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Form 3712, Page 4

40. Will you own/operate a refinery that distributes fuel from a rack?

Yes

Name

FEIN

IRS Terminal/Refinery Control Number(s) or Address

PART 7: SUPPLIER/PERMISSIVE SUPPLIER INFORMATION

Attach copies of Terminal Lease Agreements/Throughput Agreements. Please see instructions for acceptable criteria for agreements.

Yes

41. Will you own fuel products stored in terminals in Michigan?

Yes

42. Will you own fuel stored in production facilities in Michigan?

Yes

43. Will you import fuel grade ethanol into Michigan from another state or country?

Yes

44. Will you own fuel products stored in terminals in another state or country?

If yes:

Yes

a. Will you remove fuel products for your own delivery into Michigan?

Yes

b. Will you sell fuel products to customers who will deliver the fuel to Michigan?

45. Identify all owned or leased terminal storage in Michigan, and storage at out-of-state terminals from which fuel destined for Michigan will be withdrawn

(including storage at a biofuel processing plant):

Method of delivery into storage (Pipeline, Marine Vessel,

Owner or Terminal Operator

Address or IRS Terminal Control Number

Truck, Rail, Production)

PART 8: IMPORTER INFORMATION

46. If you import fuel grade ethanol into Michigan from another state or country, complete Part 7, line 43.

47. If you import fuel products, excluding ethanol, into Michigan from a Michigan licensed supplier at a terminal in another state, you must pay the Michigan

excise tax to the supplier. A license is not required for this activity.

Yes

48. Will you import fuel products by tank wagon or railcar from a bulk storage in another state?

If yes, indicate the state from which you will import, the type of license for that state, and the fuel products. You must also attach a copy of your license

for each state.

State

License Type

Products to be imported (see instructions for a list of product codes)

49. Will you import fuel products from outside the United States?

Yes

Bonded Importer – Required to submit a surety bond in an amount determined by the department, but not less than $2,000,000 unless

you are registered under IRS Sec. 4107, in which case the bond may be reduced to no less than $1,000,000.

Occasional Importer – May be required to submit a surety bond in an amount determined by the department, but not to exceed

$2,000,000. Required to pay tax on imported products within 3 days of the earliest of entry into the country or receipt of the import

verification number.

Indicate the country and/or province from which you will import, the type of fuel license you hold for that country/province, and the fuel products that you

will import. You must also attach a copy of your license for each jurisdiction.

Country/Province

License Type

Products to be imported (see instructions for a list of product codes)