Form Rev-1338 - Application For Liquid Fuels And Fuels Tax Permit
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1
2REV-1338 MF (2-13)
BUREAU USE ONLY
Amount of Surety Bond
APPLICATION FOR
$
Amount of Negotiables
Amount of L.O.C.
LIQUID FUELS AND
Total Security
BUREAU OF MOTOR AND
FUELS TAX PERMIT
ALTERNATIVE FUEL TAXES
Date Approved
PO BOX 280646
HARRISBURG, PA 17128-0646
Permit Number
FAILURE TO COMPLETE ALL APPLICABLE SECTIONS WILL RESULT IN THE REJECTION OF APPLICATION.
This application for a liquid fuels and fuels tax permit must be filed by every person refining liquid fuels or fuels in Pennsylvania for
sale or use therein and those persons importing or exporting liquid fuel or fuels. Liquid fuels include gasoline, gasohol, aviation gas
and jet fuel. Fuels include clear diesel fuel and kerosene.
Name under which the permit is to be issued (Legal Name(s), D/B/A, Fictitious Name)
1
2
Location of principal place of business (Description of exact location - PO Box is not acceptable)
Street Address
City
County
State
ZIP Code
3
MAILING Address (if different than #2) P.O. Box, Street and Number, or RD Number and Box
Street Address or PO Box
City
County
State
ZIP Code
4
Name, title, Social Security number and home address of all individual owners and elected officers constituting the ownership, partnership,
association or corporation. Attach a separate sheet if more space is required.
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
5
Applicant is operating as (check appropriate block):
An Individual
A Partnership
An Association
A Corporation
6
Are you operating under the Fictitious Names Act?
Yes
No
If yes, give date and place of registration.
Date:
Location:
7
If a corporation, are you registered with the Department of State?
Yes
No
8
If a corporation, give date, state of incorporation and PA Corporation Tax (Box) Number:
Date:
State:
PA Corporation Tax (Box) Number:
9
10
If an out-of-state corporation, give date PA Certificate of Authority was received:
Federal Employer Identification Number (FEIN)
Date:
E-mail Address
Bus. Telephone
(
)
Fax Number (
)
11
12
Home Telephone (
)
13
Name, title, home address and Social Security number of persons (other than individual owners, partners or elected officers of the partnership,
association or corporation) who are authorized to sign reports sent to the department.
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
14
14a
Date you wish to begin purchases tax free of:
Maximum month’s sales of taxable liquid fuels or fuels in PA during
Liquid fuels
past year (If you estimated the figure, write “est” behind it):
Fuels
Liquid fuel
gallons.
Both
Fuels
gallons.
15
Distributor status is requested for (check highest applicable item):
Class 1 - Refiner/Wholesaler of liquid fuels and fuels
Class 4 - Importer of liquid fuels or fuels
Class 2a - Wholesaler of liquid fuels (gasoline/gasohol only)
Class 5 - Exporter of liquid fuels or fuels
Class 2b - Wholesaler of liquid fuels (jet/avgas only)
Class 6 - Kerosene dealer
Class 3 - Wholesaler of fuels (diesel & kerosene) only
Class 6a - Kerosene dealer (blocked pumps)
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