Form Sfn 22944 - Application For Special Fuel Tax License Page 2
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211. List all special fuel storage sites in North Dakota. List each storage tank separately. (Attach addendum if necessary.)
Product
No. of
No. of
Total Tank
Type
City
County
Bulk Tanks
Retail Tanks
Capacity
*Product Types: CDSL - Clear Diesel;
DDSL - Dyed Diesel;
CKER - Clear Kerosene;
DKER - Dyed Kerosene;
HFO - Heating Fuel/Oil;
Other - Specify __________________
12. List all other special fuel tax licenses held by your company (Attach addendum if necessary):
State/Province
License Number
State/Province
License Number
List all other states and provinces in which you have special fuel tax licenses applications pending at this time:
State/Province
State/Province
Section 3: Mandatory Securities
A special fuel tax license may not be issued without the mandatory security. The security must be in an amount to cover an estimated
three months' tax liability but not less than $1,000.
Enter the security amount: $ _________________________
Check the applicable box below, and submit the security.
Surety bond
Cash bond
Letter of credit
Option for corporation or limited liability company: If you are a corporation or a limited liability company, you may elect to
provide a special security, in lieu of the above, in the form of a surety bond or a cash bond in an amount equal to your estimated
annual tax liability. This option would relieve corporate officers of a corporation or governors or managers of a limited liability
company from personal liability for failure to pay the tax due.
If your corporation or limited liability company wishes to exercise this option, contact the Motor Fuel Tax Section of the Office of
State Tax Commissioner for forms and instructions.
Section 4: Authorized Signature
I declare under the penalties of North Dakota Century Code § 12.1-11-02, which provides for a Class A misdemeanor for making a
false statement in a governmental matter, that this application has been examined by me and to the best of my knowledge and belief
(Don't forget to sign this form before submitting it)
is complete, correct, and true.
Name of owner or authorized officer (print or type)
Title
Signature of owner or authorized officer
Date
Mail application, license fee, and security to:
Motor Fuel Tax Section
For questions, call: (701)328-4576
Office of State Tax Commissioner
600 E. Boulevard Avenue
Bismarck, ND 58505-0599
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