Form Rv-F1403001 - Governmental Agency Application For Petroleum Tax Exemption Permit
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1GOVERNMENTAL AGENCY
TENNESSEE DEPARTMENT OF REVENUE
APPLICATION FOR PETROLEUM TAX EXEMPTION PERMIT
Return original and copy to Tennessee Department of Revenue, Taxpayer Services Division, Andrew Jackson State Office
Building, Nashville, TN 37242. Your permit number will be assigned and returned to you upon approval.
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2
* BUSINESS NAME AND LOCATION
BUSINESS MAILING ADDRESS
Business Name
Business Name
Street, Highway, Community
Street,or Route, P.O. Box #
City
County
State
Zip Code
City
State
Zip Code
3
IS THIS AGENCY A DIVISION OR UNIT OF ANOTHER ORGANIZATION?
No
Yes - Specify Parent Organization
4
IS APPLYING AGENCY CONSTITUTED UNDER AN ACT OF THE TENNESSEE LEGISLATURE?
No
Yes - Provide the code section reference which authorizes existing agency; T.C.A. Title No.
5
IS THIS AGENCY OPERATED WITH FUNDS PROVIDED BY ANY OF THE FOLLOWING GOVERNMENTS?
a. Federal
b. State
d. Federal
e. Other - Specify
c. County
6
IF REVENUE IS RECEIVED OTHER THAN BY DIRECT APPROPRIATION OR GRANT, IDENTIFY THE SOURCE AND EXPLAIN:
7
LIST THE GEOGRAPHICAL AREAS WITHIN WHICH THIS AGENCY RENDERS SERVICE, NAMING THE SPECIFIC COUNTY, CITY, DISTRICT, ETC.
a.
c.
e.
b.
d.
f.
8
FOR WHAT PURPOSES WILL THE EXEMPT FUEL BE USED?
a. Heating
b. Operating Stationary Equipment
Highway Vehicles
Non-Highway Vehicles
Other Uses: 1.
3.
2.
9
INDICATE GRADES AND STORAGE CAPACITY (IN GALLONS) FOR EACH GRADE OF FUEL TO BE USED: SHOW “N/A” IF NOT APPLICABLE.
a. Regular
a. Diesel
b. Premium
b. Heating Oil
GASOLINES
DISTILLATES
c. Unleaded
c. Kerosene
d. Other (Specify)
d. Jet Fuel
e. Other (Specify)
10
LIST LOCATIONS OF ALL OF THE AGENCY’S FUEL STORAGE TANKS: SHOW “N/A” IF NOT APPLICABLE.
(City)
(County)
a. (Number and Street)
(City)
(County)
b. (Number and Street)
(City)
c. (Number and Street)
(County)
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11
WILL CONTROL OF THE FUEL DISPENSED FROM THIS STORAGE BE
ARE ANY OF THE AGENCY’S STORAGE FACILITIES LEASED?
HANDLED BY THIS AGENCY?
No
No If no, By Whom
Yes
Yes
Name of Lessor
ATTACH COPY OF ALL LEASE AGREEMENTS
13
WILL THERE BE ANY EQUIPMENT SERVICED FROM THIS STORAGE OTHER THAN THAT OWNED OR LEASED BY THIS AGENCY?
No
Yes - Explain:
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15
WILL ALL OWNED AND LEASED EQUIPMENT BE OPERATED SOLELY
WHO PRESENTLY SUPPLIES FUEL TO THIS AGENCY?
BY GOVERNMENT EMPLOYEES?
(Name of Supplier)
No - Explain:
(Address)
FLEET CARD
CREDIT CARD
Yes
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STATE NAME AND TITLE OF INDIVIDUAL WHO WILL AUTHORIZE
HOW MANY HIGHWAY GOING VEHICLES WILL BE SERVICED WITH
THE TAX EXEMPT FUEL?
PURCHASES IF TAX EXEMPT FUEL.
(Name)
(Title)
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LIST ONE OR MORE OFFICIALS FOR CONTACT BY THE DEPARTMENT OF REVENUE IF PROBLEMS ARISE:
(Name)
(Title)
(Telephone, Area Code, Number) (
)
(Name)
(Title)
(Telephone, Area Code, Number) (
)
APPLIED FOR
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ENTER YOUR FEDERAL EMPLOYERS IDENTIFICATION #
NOT REQUIRED
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APPLICATION EXECUTED UNDER PENALTY OF PERJURY BY:
Signature
Official Title
Date
HAVE YOU ANSWERED EACH QUESTION COMPLETELY? AN INCOMPLETE APPLICATION WILL BE RETURNED.
* IF YOU ARE A RESCUE SQUAD, PLEASE ATTACH COPIES OF YOUR CHARTER FOR A NON-PROFIT CORPORATION AND YOUR MEMBERSHIP IN THE
TENNESSEE ASSOCIATION OF RESCUE SQUADS. IF YOU ARE A VOLUNTEER FIRE DEPARTMENT, PLEASE ATTACH A COPY OF YOUR NON-PROFIT
CORPORATION CHARTER.
RV-F1403001 (Rev. 10-02)
INTERNET (4-03)
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Parent category: Financial