Form 72a135 - Application For Kentucky Motor Fuels Tax Refund Permit printable pdf download

72A135 (4-09)

DEPARTMENT USE ONLY

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

__ __ __ __ __ __ __ __ __ __ __ __ / __ __ __ __ __ __

PERMIT NUMBER

EF DT

APPLICATION FOR

KENTUCKY MOTOR FUELS TAX REFUND PERMIT

(KRS 138.344 through 138.355)

Please type or print clearly. ALL QUESTIONS MUST BE ANSWERED.

New Application

Duplicate

Change If duplicate or change, Current Permit Number ___________________________

Applicant’s

Full Name ________________________________________________ Social Security Number __________________________________

Driver’s License Number _________________________________

Business Name

(if applicable) ________________________________________ FEIN (if business) __________________________________

Mailing Address ________________________________________________________________________________________

Street or P.O. Box

City

County

State

ZIP Code

Telephone (daytime) (

)

E-mail Address

1. Type fuel(s) for which refund permit is requested:

Agricultural Gasoline

Agricultural Special Fuels

Other Nonhighway Special Fuels

2. Description of your business or other activity for which refund fuel will be used.

Agricultural

Mining

Manufacturing

Commercial Heating

Other

Brief Description: __________________________________________________________________________________________

If applying for an agricultural permit, indicate the total number of acres owned, leased or rented for agricultural purposes.

____________________________________________________________________________________________________________

3. a. How many licensed motor vehicles do you own or operate which use gasoline? _________________________________________

b. How many licensed motor vehicles do you own or operate which use diesel fuel? _______________________________________

c. If licensed motor vehicles were indicated in line(s) 3a and/or 3b, where is fuel purchased for such licensed motor vehicles?

____________________________________________________________________________________________________________

4. a. Do you also maintain a storage tank for motor fuels to be used in licensed motor vehicles?

Yes

b. If yes, which type of fuel?

Gasoline

Special Fuels

Both

(NOTE: Criminal penalty for use of refund fuel in licensed vehicles.)

5. Provide a detailed list of all unlicensed vehicles and equipment in which refund motor fuel(s) will be used.

Attach a separate sheet if necessary.

a. Gasoline __________________________________________________________________________________________________

b. Special Fuels (diesel) ________________________________________________________________________________________

(continued on reverse)

Form 72a135 - Application For Kentucky Motor Fuels Tax Refund Permit

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