Form Tp-650 - Application For Registration Under Articles 12-A And 13-A (Page 4 of 4) in pdf

Page 4 of 4 TP-650 (12/13)

21 Only distributors of kero-jet fuel only and retail sellers of aviation gasoline should complete line 21

(attach additional sheets if necessary)

a. List all places located within NYS where you sell kero‑jet fuel or aviation gasoline.

Name of place of business

Name of airport

Location of airport (

)

Type of fuel

street, city, county

Kero‑jet

Aviation

b. Are all sales of kero‑jet and aviation gasoline delivered directly into the fuel tanks of aircraft?

Yes

c. If you are registering as a distributor of kero‑jet fuel only, do you sell any diesel motor fuel (other than kero‑jet fuel at retail) at any location within

NYS?

Yes

d. If you are registering as a retail seller of aviation gasoline, do you sell any motor fuel (other than aviation gasoline at retail) at any location within

NYS?

Yes

22 Only aviation fuel business applicants should complete line 22.

Are you an airline (see Definitions in instructions)?

Yes

If you are not an airline, would you prefer to file monthly tax returns instead of annual tax returns?

Yes

23 Signature

(all applicants must complete line 23)

I certify that all information provided is true and complete, and that this application has been completed with the knowledge that making a willfully false

written statement is a felony under Tax Law section 1812(c)(1) and a misdemeanor under Tax Law sections 1812(c)(2), 1812‑f(c)(1), and 1812‑f(c)(2)

and Penal Law section 210.45 punishable by fines and penalties therein. I further declare that this application has been completed with the knowledge

that making a false statement herein may result in the cancellation, suspension, or revocation of any license or registration issued by the Tax Department

pursuant to the tax articles to which this form applies. I also understand that the Tax Department is authorized to investigate the validity of the accuracy of

any information entered on this application.

Printed name

Signature

Title

Date

Daytime telephone number

(

)

Additional attachments required

If you are applying for a license/registration as a distributor or motor fuel, liquefied petroleum gas fuel permittee, distributor of diesel motor fuel, retailer of

non‑highway diesel motor fuel only, distributor of kero‑jet fuel only, residual petroleum product business, or retail seller of aviation gasoline, you must submit:

• a current financial statement (to register as a distributor of motor fuel, your current financial statement must be a certified, unqualified statement); and

• a letter from each supplier that includes the following information:

– the quantity and type of product that they agree to supply to you each month;

– payment and/or credit terms; and

– the terminals from which the fuel will be shipped and the method of shipment (ocean vessel, barge, tank truck, pipeline, etc.).

If you are not currently registered as a sales tax vendor, you must apply and receive your NYS Certificate of Authority before this application will be approved

for licensing/registration. You may apply online by using the NYS License Center at

The Tax Department will notify you if you are required to file a bond or other acceptable security (see Bonding requirements in instructions).

Mail completed application and all required documents to:

NYS TAX DEPARTMENT

TDAB/FACCTS-REGISTRATION AND BOND UNIT

W A HARRIMAN CAMPUS

ALBANY NY 12227