Form Fut-6 - Excise And Motor Fuel Tax
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1FUT-6
Excise and Motor Fuel Tax
(Rev 4/01)
P. O. Box 530
Columbus, OH 43216-0530
(614) 466-3921
Fax (614) 728-8085
APPLICATIONS NOT COMPLETED IN ACCORDANCE WITH THESE INSTRUCTIONS WILL BE RETURNED.
(Please Print Or Type)
(1) If you are an individual, enter your last, first and middle name. If partnership, enter the full name of the
partners. If incorporated, enter corporate name.
(2) Enter your legal address.
(3) Enter both telephone number and fax number.
(4) If you are an individual, enter social security number. If partnership, enter social security numbers of all
partners. If incorporated, LLC or LLP, enter federal employer identification number.
(5) Check only one box.
(6) Enter the number of sets of permits needed. Order only as many as needed. You are required to account
for every permit issued to you for the current year and the previous 3 years. Permits will be mailed to the
address listed on line 2 below within two working days of receipt of this application. Please mail the form to
the above address or fax it to the number shown above.
(7) Indicate if all of your vehicles are farm plated.
(8) OPTIONAL – If you need immediate authority to run, check “yes” to have a temporary authority faxed to you
at the fax number listed on line 3.
8A). Enter vehicle identification number upon receipt of validated
temporary authority . Note: You may reproduce a validated temporary authority for up to the number of
permits requested on line 6. A temporary authority is valid for 30 days.
(9) Sign and date application.
(10) Ohio Department of Taxation validation stamp.
Federal Privacy Act of 1974
Because we are requesting your social security account number, the Federal Privacy Act of 1974 requires us to inform you that giving us your social security
number is mandatory. Our legal right to ask for this information is supported under the Tax Reform Act of 1986. Your social security number is needed for
the Tax Commissioner to administer this tax. Failure to supply any information requested on a tax form prescribed by the Tax Commissioner may result in
the denial of your license application, if applicable, or the imposition of penalties for failing to file a complete tax return.
(614) 466-3921
Fax: (614) 728-8085
Telephone:
_________________________
Account No.
APPLICATION FOR FUEL USE PERMIT
Social Security Number
__________________________________________________________________
1. Name
4.
)
)
)
(Last
(First
(Middle
___________________________________________________________
2. Legal Address
Social Security Number
________________________________________________________________________
(City)
(State)
(Zip Code)
Federal Employer Identification Number
(_____) _____ - _________
(_____) _____ - _________
3. Phone Number
Fax Number
5.
c
c
Individual
Partnership
Number of Permits Needed
Are all of these vehicles farm plated?
6.
7.
c
c
c
c
Yes
No
Corporation
Other
F
T
A
U
O
10.
8.
TEMPORARY PERMIT NOT VALID UNLESS STAMPED
OR
EMPORARY
UTHORITY
SE
NLY
Do you wish to have a temporary authority
8A.
Vehicle Identification Number
c
faxed to you?
Yes
I declare under the penalties of perjury that this application (including any accompanying
statements) has been examined by me and to the best of my knowledge and belief is a true,
correct, and complete application.
9.___________________________________________________________________________________
Signature
Date
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