Form 20mf - Nebraska Motor Fuels License Application Page 2
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416 Will you export fuel from Nebraska to 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
17 Have any licenses or permits issued to you under the motor fuels laws of another state been suspended, cancelled, or revoked? . . .
YES
NO
If Yes, list the states and license numbers. Attach an additional schedule, if necessary.
State
License Number
18 Has any owner, partner, member, or corporate officer of this business been convicted of a felony in the last ten years? . . . . . . . . . . .
YES
NO
19 Do you have storage tanks that are required to be registered with the State Fire Marshal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, are all storage tanks registered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
20 Do you sell motor fuels or compressed fuel through metered dispensing devices (pumps)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, are the dispensing devices registered with the Nebraska Department of Agriculture Weights and Measures Division? . . . . . . .
YES
NO
MULTIPLE NEBRASKA RETAIL LOCATION INFORMATION
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Attach an additional page, if necessary. Include all fuel types.
B What type of fuel is sold from this retail location? Check all that apply.
A What type of fuel is sold from this retail location? Check all that apply.
Motor Fuels
Aircraft Fuels
Compressed Fuel
Motor Fuels
Aircraft Fuels
Compressed Fuel
Retail Location Name
Retail Location Name
Retail Location Street Address
Retail Location Street Address
City
State
Zip Code
City
State
Zip Code
C What type of fuel is sold from this retail location? Check all that apply.
D What type of fuel is sold from this retail location? Check all that apply.
Motor Fuels
Aircraft Fuels
Compressed Fuel
Motor Fuels
Aircraft Fuels
Compressed Fuel
Retail Location Name
Retail Location Name
Retail Location Street Address
Retail Location Street Address
City
State
Zip Code
City
State
Zip Code
ELECTRONIC DATA INTERCHANGE (EDI) — required for all licenses except Motor Fuels Retailer and Liquid Fuel Carrier.
22
Translation by (check one):
Commercial EDI Software
Online Filing (Motor Fuels Use Tax and Compressed Fuel Tax only)
Internally Created Software from the Motor Fuels Division EDI Implementation Guide
EDI Email Contact Address (if different from line 9)
Pursuant to the provisions of
Neb. Rev. Stat. §
66-718, applicant agrees as follows:
The signature of the taxpayer or authorized agent is deemed to appear on electronically filed reports or returns.
All reports and returns filed electronically by the taxpayer are truthful, accurate, and complete statements made
under penalty of perjury. The taxpayer’s electronically filed reports and returns are in a form and manner compatible
with the State of Nebraska, Department of Revenue’s equipment, software, facilities, and electronic filing standards.
Any electronic filing not in conformity is considered a failure to file the report or return and the taxpayer will be
subject to all applicable penalties prescribed by law. The taxpayer is responsible for all costs associated with the
transmission of electronically filed reports and returns. The place of performance pursuant to this application shall
be Lincoln, Nebraska.
sign
here
Signature of Owner, Partner, Member, Corporate Officer, or Person Authorized by Attached Power of Attorney
Date
Title
Phone Number
Mail this application and required bonds to: MOTOR FUELS DIVISION, PO BOX 98904, LINCOLN, NE 68509-8904.
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Parent category: Financial