Form R-5409 - Motor Fuel Excise Tax License Application
Download a blank fillable Form R-5409 - Motor Fuel Excise Tax License Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form R-5409 - Motor Fuel Excise Tax License Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4R-5409 (7/06)
Date of Application _________________________
Motor Fuel Excise Tax License Application
Mail to:
Louisiana Department of Revenue
Taxpayer Services Division
Excise Taxes Section
P. O. Box 66362
Baton Rouge, LA 70896-6362
(225) 219-7656 (225) 219-2114 (TDD)
Please Print or Type.
A. Applicant Information
Legal Business or Corporation Name
LA Account Number
Trade Name or DBA (if different from Business Name)
FEIN/SSN
Contact Person
Telephone Number
Fax Number
E-Mail Address
B. Address Information
Physical Location (do not list P.O. Box)
City
State
ZIP
Mailing Address (if different from above)
City
State
ZIP
Address of Business Records
City
State
ZIP
C. License Information
Check each license for which you are applying
❐
❐
❐
❐
❐
Supplier
Importer
Terminal Operator
Motor Fuel Transporter
Aviation Fuel Dealer
❐
❐
❐
❐
Permissive Supplier
Exporter
Blender
Distributor
List business license number(s) for the following (if applicable)
IFTA License Number
IRP License Number
Federal Registry Certificate Number
Type of Registry
Enter 9-digit number assigned by the Secretary of State’s Office, if applicable. You must have a number
to submit this application, except for sole proprietorship or general partnership.
D. Type of Business Ownership
❐
❐
❐
❐
Sole Proprietorship
General Partnership
Joint Venture
Other (specify below)
❐
❐
❐
________________
Domestic Corporation
Limited Partnership
Association
❐
❐
❐
Foreign Corporation
Limited Liability Partnership
Limited Liability Company
CORPORATION: provide all corporate officers. PARTNERSHIP: provide all partners. SOLE PROPRIETORSHIP: provide owner.
ALL OTHERS: provide all general partners, members, or managers. (Attach additional pages if necessary.)
Full Legal Name
Social Security Number
Title
Home Address
City
State
ZIP
Full Legal Name
Title
Social Security Number
Home Address
City
State
ZIP
Full Legal Name
Social Security Number
Title
Home Address
City
State
ZIP
If your business organization is a partnership, sole proprietorship, or your business is based in another state you must provide an agent
for service of process. If you are applying for an Exporter’s License, you must provide a Louisiana Registered Agent.
Name
Telephone Number
E-mail address
Fax Number
City
State
ZIP
Address
Page 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial