Form 20mf - Nebraska Motor Fuels License Application
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Nebraska Motor Fuels License Application
FORM
• Complete both sides of the application.
20MF
• Please print clearly.
PLEASE DO NOT WRITE IN THIS SPACE
1 Do you hold or have you previously held a Nebraska ID Number?
YES
NO
If Yes, provide ID number:
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
2 Federal Employer ID or Social Security Number
3 First Day of Business
Effective Date of License
4 LEGAL NAME & LOCATION ADDRESS OF BUSINESS
5 NAME & MAILING ADDRESS OF BUSINESS
Legal Name
Name
Name Doing Business As (dba)
Name Doing Business As (dba)
Name of Division, Name of Building, Suite Number, etc.
Name of Division, Name of Building, Suite Number, etc.
Street Address
Address
City
State
Zip Code
City
State
Zip Code
6 Are retail sales made at this location?
YES
NO
If Yes, what type of fuel is sold from this retail location? Check all that apply.
Motor Vehicle Fuels
Aircraft Fuels
Diesel Fuels
Dyed Diesel Fuels
Compressed Fuels
7 Contact Name
8 Contact Phone Number
9 Contact Email Address
10 Fax Number
11 Identify Owner, Partners, Members, or Corporate Officers (One of the individuals listed must sign as the Applicant.)
Social Security Number
Name, Address, City, State, Zip Code
Title, If Corporate Officer
12 Check all levels of operation for motor fuels and aircraft fuels. The license will be issued to the highest level of operation.
Ethanol Producer
Biodiesel Producer
Supplier
Distributor
Importer
Wholesaler
Exporter
Retailer
13 Check the types of licenses being applied for (if a bond is required, attach Form 70):
AIRCRAFT FUELS & PETROLEUM RELEASE REMEDIAL ACTION FEE (includes aviation jet fuel and aviation gasoline) — Bond Required
MOTOR FUELS & PETROLEUM RELEASE REMEDIAL ACTION FEE (includes gasoline, gasohol, ethanol, ethanol blends, undyed diesel, biodiesel,
biodiesel blends, dyed diesel, dyed diesel blends, and natural gasoline) — Bond Required
PRODUCER LICENSE & PETROLEUM RELEASE REMEDIAL ACTION FEE (includes ethanol & biodiesel) — Bond Required
COMPRESSED FUEL RETAILER — Bond Required. See back to add multiple retail locations.
Indicate type of fuel sold:
Propane
Natural Gas
Other
LIQUID FUEL CARRIER
MOTOR FUELS RETAILER — Separate license required for each retail location. See back to add multiple retail locations.
MOTOR FUELS USE TAX
TERMINAL OPERATOR
14 Type of Ownership:
Cooperative
Fiduciary
Limited Liability Company
Partnership
Domesticated Corporation
Foreign Corporation
Nonprofit Corporation
Sole Proprietorship
Domestic Corporation
Governmental
Nonprofit Organization
15 Will you import fuel into Nebraska from another state?
YES
NO
If Yes, list the states, license numbers, and type of fuel. Attach an additional schedule, if necessary.
State
License Number
Type of Fuel
8-2012
3-317-1991 Rev.
CONTINUED ON REVERSE SIDE
Supersedes 3-317-1991 Rev. 2-2011
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