Form 795 - Missouri Motor Fuel Tax License Application Page 6
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SECTION 14 — MISSOURI STORAGE TANK INFORMATION (ATTACH LIST IF NECESSARY)
LIST STORAGE TANK INFORMATION BY PRODUCT TYPE, CITY OR TOWN LOCATION, TOTAL TANK CAPACITY PER CITY OR TOWN AND THE COUNTY.
PRODUCT TYPES
GASOLINE ALCOHOL GASOHOL AVIATION GAS UNDYED DIESEL DYED DIESEL UNDYED KEROSENE DYED KEROSENE JET FUEL OTHER (LIST)
PRODUCT TYPE
CITY OR TOWN
TOTAL TANK CAPACITY
COUNTY
SECTION 15 — BOND INFORMATION
ESTIMATED NUMBER OF GALLONS OF FUEL HANDLED PER MONTH PER ACTIVITY TYPE:
ACTIVITY TYPE
LIST GALLONS HANDLED BY PRODUCT TYPES AS GROUPED BELOW
SUPPLIER/PERMISSIVE
GAS,
DIESEL, DYED DIESEL
AV
JET
SUPPLIER
GASOHOL
KEROSENE
GAS
FUEL
ALCOHOL
GAS,
DIESEL, DYED DIESEL
AV
JET
TERMINAL OPERATOR
GASOHOL
KEROSENE
GAS
FUEL
ALCOHOL
GAS,
DIESEL, DYED DIESEL
AV
JET
DISTRIBUTOR
GASOHOL
KEROSENE
GAS
FUEL
ALCOHOL
GAS,
DIESEL, DYED DIESEL
AV
JET
TRANSPORTER
GASOHOL
KEROSENE
GAS
FUEL
ALCOHOL
Enter dates as mm/dd/yyyy.
SUPPLIER/PERMISSIVE SUPPLIER BOND
- 3X MONTHLY LIABILITY BASED ON NUMBER OF GALLONS HANDLED (MINIMUM $100,000 - MAXIMUM $2,000,000)
SURETY BOND
CERTIFICATE OF DEPOSIT
LETTER OF CREDIT
CASH BOND
*PROOF OF FINANCIAL RESPONSIBILITY
NAME & ADDRESS OF INSURANCE
BONDING INSTRUMENT NUMBER _________________________________
COMPANY OR BANKING INSTITUTION ____________________________________________________________________
BOND AMOUNT _______________________________________________
DATE ISSUED ____________________________________________
*
PROOF OF FINANCIAL RESPONSIBILITY MAY BE PROVIDED FOR THE ENTIRE BOND, 1/2 OF THE REQUIRED BOND OR 1/4 OF THE REQUIRED BOND (SUBMIT ANNUAL FINANCIAL REPORT)
1. $5,000,000 NET WORTH IN LIEU OF TOTAL BOND AMOUNT REQUIRED
2. $2,500,000 NET WORTH IN LIEU OF 1/2 OF BOND AMOUNT REQUIRED
NET WORTH IS CALCULATED ON A COMPANY, NOT INDIVIDUAL STATE BASIS
3. $1,250,000 NET WORTH IN LIEU OF 1/4 OF BOND AMOUNT REQUIRED
TERMINAL OPERATOR BOND
- 3X MONTHLY LIABILITY BASED ON NUMBER OF GALLONS HANDLED (MAXIMUM OF $500,000)
SURETY BOND
CERTIFICATE OF DEPOSIT
LETTER OF CREDIT
CASH BOND
NAME & ADDRESS OF INSURANCE
BONDING INSTRUMENT NUMBER _________________________________
COMPANY OR BANKING INSTITUTION ____________________________________________________________________
BOND AMOUNT _______________________________________________
DATE ISSUED ____________________________________________
DISTRIBUTOR BOND - 3X MONTHLY LIABILITY BASED ON NUMBER OF GALLONS HANDLED (MAXIMUM OF $150,000 FOR GAS, $150,000 FOR DIESEL FUEL SEPARATELY)
SURETY BOND
CERTIFICATE OF DEPOSIT
LETTER OF CREDIT
CASH BOND
***POOL BOND
NAME & ADDRESS OF INSURANCE
BONDING INSTRUMENT NUMBER _________________________________
COMPANY OR BANKING INSTITUTION ____________________________________________________________________
BOND AMOUNT _______________________________________________
DATE ISSUED ____________________________________________
***
POOL BOND— DISTRIBUTORS THAT WERE LICENSED PRIOR TO JANUARY 1, 1999 AND WERE NOT REQUIRED TO PROVIDE A BOND UNDER THE PREVIOUS LAW OR DISTRIBUTORS
LICENSED AFTER JANUARY 1, 1999 WITH THREE (3) CONSECUTIVE YEARS OF SATISFACTORY TAX COMPLIANCE, AS DETERMINED BY THE DIRECTOR, MAY ELECT TO PARTICIPATE
IN THE POOL BOND. THE CURRENT POOL BOND RATE IS .0024 PER GALLON OF MOTOR FUEL AND .0013 PER GALLON OF AVIATION FUEL BASED ON ALL GALLONS PURCHASED IN
MISSOURI OR ON ALL GALLONS IMPORTED INTO MISSOURI.
TRANSPORTER BOND - 3X MONTHLY LIABILITY BASED ON NUMBER OF GALLONS HANDLED (MAXIMUM OF $100,000)
SURETY BOND
CERTIFICATE OF DEPOSIT
LETTER OF CREDIT
CASH BOND
NAME & ADDRESS OF INSURANCE
BONDING INSTRUMENT NUMBER _________________________________
COMPANY OR BANKING INSTITUTION ____________________________________________________________________
BOND AMOUNT _______________________________________________
DATE ISSUED ____________________________________________
SECTION 16 — SIGNATURE
Under the penalty of perjury, I hereby certify that information contained herein is true, complete and correct. If indicated in Section 3, I hereby elect to obtain “eligible purchaser” status.
COMPANY NAME
SIGNATURE OF OWNER, PARTNER OR AUTHORIZED OFFICER
PRINT NAME OF PERSON SIGNING THE APPLICATION
DATE
__ __ / __ __ / __ __ __ __
DOR-795 ( 11-2011)
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