Form 80-001 - Iowa Motor Fuel Tax License Application
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Iowa Department of Revenue
80-001
Iowa Motor Fuel Tax License Application
(4/21/09)
I. LOCATION NAME/ADDRESS
IV. TYPES OF MOTOR FUEL LICENSES
Federal ID Number (if any):______________________________
Check the appropriate types of licenses for which you are applying.
If you are in the process of applying for a
Start Date: ___________________ (The date of your first
FEIN, write “applied for” on this line.
transaction for the fuel license you are applying for)
Social Security Number: ________________________________
Note: Payments are required to be made through eFile & Pay or by
Owner (legal) Name: ___________________________________
ACH Credit. If using ACH Credit, form 92-116 must be completed.
Payment by credit card is not an option.
Business (trade) Name: _________________________________
Liquefied Petroleum Gas Consolidated Location (00) eFile and
Street Address: ________________________________________
electronic payment required. If you are adding a dealer/user
location to a consolidated location number, write your
Do not give a post office box.
consolidated location number here: _____________________
City: ____________________ State: _____ Zip: _____________
Liquefied Petroleum Gas Dealer (01)
eFile and electronic payment required
Liquefied Petroleum Gas User (02)
eFile and electronic payment required
If in Iowa, County: _____________________________________
Supplier (04)
eFile and electronic payment required
County Number: ______________________________
Restrictive Supplier (05)
eFile and electronic payment required
Importer (06)
eFile and electronic payment required
Phone #: ___________________________ Ext. _______
Blender (07)
eFile and electronic payment required
Fax #: _____________________________
Bio
E85
Kerosene
Ethanol
Compressed Natural Gas Consolidated Location (08)
E-mail: ____________________________
Compressed Natural Gas Dealer (09)
Compressed Natural Gas User (10)
II. MAILING NAME/ADDRESS
Exporter (11) List all states to which fuel will be exported.
Attach additional pages if necessary.
If your mailing address is different than the location of your
State: __________ License Number: ____________________
business, complete this section.
Eligible Purchaser (12) You must complete form 80-011.
Name: _______________________________________________
Eligible Purchaser End User (13) You must complete
form 80-011.
Mailing Address: ______________________________________
IRS Terminal
Ethanol Plant (14)
eFile required
City: ____________________ State: _____ Zip: _____________
Biodiesel Plant
Marketer (14)
eFile required
Transportation (15)
eFile required
Phone #: ___________________________ Ext. _______
Environmental Protection Charge (18)
Fax #: _____________________________
E-mail: ____________________________
V. CURRENT/PRIOR BUSINESS ACTIVITY
Starting date of the business: _____________________________
III. TYPE OF OWNERSHIP (check one)
Do you currently operate a business at another location in Iowa?
Sole Proprietor
Partnership
YES
NO
If yes, complete the following:
Corporation
Association
Sales Tax Permit No.: __________________________________
Government
Limited Liability Co.
Motor Fuel License No.: ________________________________
Incomplete applications delay processing.
Withholding FEIN No.: _________________________________
EPC Permit No.: _______________________________________
FOR OFFICE USE ONLY
If you are purchasing this business, give the previous owner’s name:
____________________________________________________
PERMIT NUMBER
Did you previously have an Iowa Motor Fuel license?
_________________________________
YES Number: _____________________
NO
_________________________________
VI. SIGNATURE
_________________________________
This application must be signed by the owner,
_________________________________
one of the partners or a corporate officer.
_________________________________
Signature: _______________________________________ Date: _________________
_________________________________
Print name here: _______________________ Social Security Number: _____________
_________________________________
CONTINUE ON OTHER SIDE
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