Form Mf 204 - Application For License As A Motor Fuel Exporter Type A Or B Page 2
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2MF 204
Rev. 3/00
Page 2
11. Type of license requested (check one)
TYPE A – In order to be licensed as an exporter Type A, applicant must be licensed to collect and remit taxes
directly to the state taxing authority where the fuel is destined. You must attach a copy of your license or certifi cate to
collect and remit motor fuel taxes or sell or distribute motor fuel in the specifi ed destination state or states for which this
license is to be issued.)
TYPE B – In order to be licensed as an exporter Type B, applicant must certify in the space following that the
applicant is statutorily prohibited from obtaining a license to collect and remit motor fuel taxes in the specifi ed state of
destination, and that the person is licensed to sell or distribute tax-paid motor fuel in the specifi ed state of destination.
If the requirements outlined for a “Type B” license are true, please sign immediately following:
I certify that I/we meet the requirements outlined for a Type B exporter license.
Authorized signature
Title
Date
12. Do you maintain accurate and detailed records of all motor fuel receipts and disbursements?
Yes
No
If yes, how long are records kept?
13. Have you, any partner, member or a corporation in which you or any other partner or member had greater than 5%
interest ever had an exporter’s license revoked by any state, federal government or province?
Yes
No
If yes, provide the state, etc., the reason for revocation and the date or revocation.
14. What is the estimated monthly gallonage you intend to export?
It is understood that upon approval of this application, the applicant will comply with all of the laws/requirements as applicable
under Ohio Revised Code Chaper 5735. Failure to comply with applicable law could result in revocation of license, assessment
of tax and penalties, and possible criminal prosecution.
Signature of dealer or offi cer of company
Title
Date
Sworn to before me and in my presence subscribed this
day of
20
.
Notary public
Return completed application to the Ohio Department of Taxation, Motor Fuel Tax Refund Unit, P.O. Box 530, Columbus, OH
43216-0530. Retain copy for your fi les. Direct any questions to (855) 466-3921 or fax (614) 752-8644.
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