Form 72a073 - Application For Approval To Receive A Refund Of Tax On Motor Fuels Consumed By City And Suburban Buses, Nonprofit Buses, Senior Citizen Transportation, And Taxicabs
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1Must be accompanied by
72A073 (4-09)
APPLICATION FOR APPROVAL TO RECEIVE
corporate surety bond.
Commonwealth of Kentucky
(Form 72A071)
A REFUND OF TAX ON MOTOR FUELS
DEPARTMENT OF REVENUE
CONSUMED BY
CITY AND SUBURBAN BUSES, NONPROFIT BUSES,
SENIOR CITIZEN TRANSPORTATION, AND TAXICABS
Name_________________________________________________________________ DBA _________________________________
Street _________________________________________________________________________________________________________
City _______________________________________
State __________________________
ZIP Code ______________________
(
)
Telephone Number (include Area Code) ____________________________
E-mail Address _________________________________
Federal Employer Id Number ___ ___ – ___ ___ ___ ___ ___ ___ ___
Indicate the type of organization:
city and suburban bus company
nonprofit bus company
senior citizen transportation organization
taxicab company
Number as shown on certificate for taxicabs (if applicable) ______________________________________________________________
Number of vehicles operated ______________________________________________________________________________________
Does your group utilize Title III funds of the Older Americans Act in the provision of transportation services?
Yes
No
Address at which records are available for audit: Number and Street _______________________________________________________
City _______________________________________
County ___________________
State ____________ ZIP Code _________
Number of gallons of motor fuels used in previous 12-month period _______________________________________________________
Does your company have bulk storage facilities?
Yes
No
City of operation ________________________________________________________________________________________________
Have you ever had any license suspended or revoked which had been issued to you by the Commonwealth of Kentucky?
Yes
No If answer is yes, attach a detailed explanation.
Indicate the type of ownership:
Individual
Partnership
Corporation
Limited Liability Corporation
Limited Liability Partnership
Other (describe) _________________________________________________________________________________________
List names and addresses of partners or principal officers of corporation.
Name
Title
Address
FEIN or SSN
______________________________
__________________
______________________________
____________________
______________________________
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I declare under penalties of perjury that this application is made in good faith, and the answers given to the questions are true and correct
to the best of my knowledge and belief.
______________________________
_________________________
_______________________
____________________
Print Name
Title
Date of Application
Signature of Applicant
Mail application to Motor Fuels Tax Compliance Section,
Department of Revenue, P.O. Box 1303, Frankfort, Kentucky 40602-1303.
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