Form 04-407 - Qualified Dealer License Application/renewal
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4Alaska Department of Revenue
Department of Revenue
Tax Division
Qualified Dealer License Application/Renewal
PO Box 110420
15 AAC 40.045
Juneau, AK 99811-0420
We will issue your license in the name of the individual or corporation shown below. A separate application is required for each location.
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Is this a renewal?
YES
NO
Th
LICENSEE INFORMATION
License Number, if renewal
Federal EIN or SSN of Owner
Taxpayer Name
Entity Type:
Corporation
Partnership
Individual
LLC
er
Business Name
MAILING ADDRESS
PO Box or Street Address
Telephone Number
Fax Number
City
State
Zip CodeE-mail Address
PHYSICAL LOCATION WHERE
FUEL IS SOLD ¨ Address
same as mailing address
Street address or physical description
City
State
Zip Code
LICENSE TYPE
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Check the appropriate box:
Refines, blends, imports, manufactures, and/or produces motor fuel:
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Sells at least 20 percent of fuel to another party for resale and/or for residential heating purposes.
AFFIDAVIT OF ESTIMATED TAX
(If at any time during the year these estimates are lower than actual gallons subject to tax, you must file a corrected
affidavit and comply with any additional security requirements. The corrected affidavit and additional tax security is due 30 days after you have knowledge of
the underestimate.)
Estimated Monthly Sales (Gallons)
Tax Rates
Tax Liability
Jet Fuel
X
$0.032
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Aviation Gas
X
$0.047
Marine – diesel & gasoline
X
$0.05
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Highway – diesel, gasoline &
X
$0.08
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gasohol
Total Estimated Tax on Maximum Inventory (Add amounts in this column)
Your estimated maximum monthly tax liability must be secured either by a qualified dealer bond, cash, letter of credit, or certificate of deposit from an Alaska
bank, or real property. Check one:
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Qualified Dealer Bond in an amount equal to twice the average monthly motor fuel tax remittance but not less than $5,000
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Cash, letter of credit or certificate of deposit from an Alaska bank in an amount equal to twice the average monthly motor fuel tax remittance
but not less than $5,000
Real property in Alaska on which motor fuel taxes may become a first lien and where the fair market value is equal to twice the amount of the total
estimated monthly tax on maximum inventory. You must attach a title search (current within 30 days of the application) along with either a current property
tax assessment notice or independent market appraisal.
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Form 04-407 (Rev 07/00)
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