Form Mf-180 - Application For Kansas Qualified Biodiesel Fuel Producer Incentive
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2KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
FOR OFFICE USE ONLY
915 S.W. HARRISON ST.
TOPEKA, KANSAS 66625-8000
DATE RECEIVED:
Phone Number: (785) 368-8222
DATE APPROVED:
Fax: (785) 296-4993
APPLICATION FOR
KANSAS QUALIFIED BIODIESEL FUEL PRODUCER INCENTIVE
an individual-partnership-corporation
Name:
(Strike out terms that do not apply)
of
(Zip)
(County)
(State)
(Street address)
(City)
hereby makes application to the Department of Revenue, Division of Taxation, Topeka, Kansas 66625-8000, for the Kansas
Qualified Biodiesel Fuel Producer Incentive.
1. The full and correct name of applicant is: (List names, title and address of each partner or officer. Attach a copy
of the Articles of Incorporation or the Articles of Organization.)
NAME
TITLE
FULL ADDRESS
2. Federal Employers Identification Number or SSN if an individual.
3. Principal mailing address of applicant:
(Street address)
(City)
(Zip Code)
(State)
4. List the physical location in Kansas where the applicant produces biodiesel.
5. Indicate whether the location is owned or leased by the applicant.
6. Annual plant production capacity:
7. Feedstock materials to be used in the production of biodiesel. (Check all boxes that apply).
o
Soybean oil.
o
Canola oil.
o
Recycled cooking oil.
o
Animal fat.
o
Other (Describe)
8.
Production start date:
Include a copy of your Certificate of Analysis verifying the biodiesel produced meets the ASTM standards.
Conditions:
Applicant has made no false statements as to any material fact in this application.
Applicant has complied with all State and Federal laws.
All persons employed by applicant in good faith agree to observe and conform to all of the terms and conditions.
STATE OF ___________________________ )
) SS:
COUNTY OF _________________________ )
I, ___________________________________________________ first being fully sworn, state that the above application and all
statements and conditions contained therein, are true and correct.
(Signature)
(Title)
Subscribed and sworn to before me, this ___________ day of _______________________________________________ , 20 __________
My commision expires ________________________ 20 __________
____________________________________________________
(Notary Public)
MF-180
Rev. (2/07)
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