Form 4099 - Motor Fuel Electronic Filing Application

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OFFICE USE ONLY
Michigan Department of Treasury
4099 (Rev.7-09)
UserID
Motor Fuel Electronic Filing Application
Date
Issued under authority of P.A. 403 of 2000, as amended.
Initials
INSTRUCTIONS: Based on your average tax return filing size, choose either to file by using the Web Direct Fillable Forms filing option
or using the File Transfer Protocol (FTP) filing option.
Company Name
Application Date
Mailing Address
City
State
ZIP Code
FEIN Number
Phone Number
Fax Number
Electronic Filing Contact Person
Contact Person Phone Number
Contact Person Email Address
FILING OPTIONS (Select only one option)
Web Direct Fillable Forms
NOTE: Liquefied Petroleum Gasoline (LPG) Dealers, Retail
Marine Diesel Dealers and Terminal Operators (annual returns
only) must file using Web Direct Fillable Forms filing option.
File Transfer Protocol (FTP)
You MUST select a TRANSMISSION FORMAT METHOD FOR FTP OPTION:
ANSI X.12 813 4030
ASCII Flat File
FTP file specifications can be found on our e-file Web site:
INTERNET FTP SERVER DISCLAIMER: The system is for the use of authorized clients only. Individuals using the computer network
system without authorization, or in excess of their authorization, are subject to having all their activity on this computer network system
monitored and recorded by system personnel. To protect the computer network system from unauthorized use and to ensure the
computer network systems is functioning properly, system administrators will monitor this system. Anyone using this computer
network system expressly consents to such monitoring and is advised that if such monitoring reveals possible conduct of criminal
activity, system personnel may provide the evidence of such activity to law enforcement officers. Access is restricted to authorized
users only. Unauthorized access is a violation of state, federal, civil and criminal laws.
AUTHORIZATION
Licensee identification number and password, when included as part of the report filed pursuant to this Agreement, shall constitute the
signature of the Licensee on the Report as if such Report were actually signed by the Licensee. In addition, the transmission using the
Licensee identification number and password will act as certification of sales that the 1.5% allowance was passed on to Wholesalers
and 1/3 of the 1.5% allowance was passed on to Retailers pursuant to statute. Each party shall adopt as its signature an electronic
identification consisting of codes in each electronic transmission transmitted by such Party (the "Signature"). Each party agrees that
any Signature of a Party affixed to or contained in any transmitted electronic transmission shall be sufficient to verify the Party
originated such electronic transmission. Neither Party shall disclose to any unauthorized person the Signature of the other Party.
Each Party agrees to maintain adequate back-up files to recreate electronic transmission as required. Back-up files shall be subject to
the terms of this Agreement to the same extent as the original data. Electronic transmissions shall be retained for such periods as
required by relevant Michigan statutes.
Authorized Signature
Title
Date
Send applications to:
Michigan Department of Treasury
Special Taxes Division - Motor Fuel
P.O. Box 30474
Lansing, MI 48909-7974
(517) 636-4600

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