Indiana Department of Revenue
MF-627
Cancellation of License
State Form 49115
(R5 / 6-13)
Company Name
DBA
Address
City
State
Zip Code
Please provide a license number for all license types you wish to cancel.
1. Effective Date of Cancellation: ______________________________________________________________________________
2. Gasoline Distributor’s License Number: _______________________________________________________________________
3. Oil Inspection Distributor’s License Number: ___________________________________________________________________
4. Aviation Fuel Dealer’s Number: _____________________________________________________________________________
5. Marina Fuel Dealer’s Number: ______________________________________________________________________________
6. Special Fuel Importer’s License Number: _____________________________________________________________________
7. Special Fuel Transporter’s License Number: ___________________________________________________________________
8. Special Fuel Exporter’s License Number: _____________________________________________________________________
9. Special Fuel Supplier’s License Number: _____________________________________________________________________
10. Special Fuel Permissive Supplier’s License Number: ____________________________________________________________
11. Special Fuel Terminal Operator’s License Number: _____________________________________________________________
12. Special Fuel Blender’s License Number: ______________________________________________________________________
13. Special Fuel Dyed User’s License Number: ___________________________________________________________________
14. Special Fuel Eligible Purchaser’s License Number: _____________________________________________________________
15. Petroleum Severance License Number: ______________________________________________________________________
16. Indiana Prepaid Number: _________________________________________________________________________________
17. Gasohol Blender License: _________________________________________________________________________________
18. Aviation Fuel Excise Number: ______________________________________________________________________________
Taxpayer Identification Number (TID): ____________________
Date Signed: ___________________________________
Signature: _________________________________________
Printed Name: __________________________________
Title: ______________________________________________
Telephone Number: ______________________________