Form Mfa-1 - Combined Motor Fuels License Application Page 9

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Section 15 – Notice of Election for Suppliers and Permissive Suppliers

THIS NOTICE OF ELECTION PROVIDES FOR THE PRECOLLECTION OF THE NEW JERSEY MOTOR FUEL TAX ON ALL REMOVALS FROM

ALL OUT-OF-STATE TERMINALS LISTED IN SECTION 12 WHERE SUPPLIERS OR PERMISSIVE SUPPLIERS ARE POSITION HOLDERS.

We elect to treat all removals from all out-of-state terminals with a destination into New Jersey as shown on the terminal-issued shipping

papers as if the removals were removed across the rack by the supplier from a terminal in New Jersey as provided in Section 54:39-118.

We agree to precollect the New Jersey motor fuel tax in accordance with Chapter P.L 2010. C22 on all removals from a qualified terminal

where we are a position holder without regard to the license status of the person acquiring the fuel, the point of terms of the sale or the character of

delivery.

We further agree to waive any defense that the State of New Jersey lacks jurisdiction to require collection on all out-of-state sales by such

person as to which the person had knowledge that the shipments were destined for New Jersey and that New Jersey imposes the requirements under

its general police powers to regulate the movement of motor fuels.

NOTICE OF ELECTION must be signed by an authorized representative of the company as listed in Section 5 of this

application.

Signature

Title

Printed Name

Date Signed

Section 16 – Application to be a Qualified Distributor

Pursuant to Section 54:39-121, Qualified Distributors may delay remittance of the tax precollected by their Suppliers and Permissive Suppliers until up to the

day of the month following the removal of taxable products from a terminal by a fuel transportation vehicle. Payments made to Suppliers and Permissive

Suppliers MUST be made by EFT.

We acknowledge our Suppliers’ obligations to precollect tax due on Motor Fuels from us, hold it in trust for New Jersey, and remit the

precollected tax no later than the 22

of the month following the taxable event.

We affirm that:

Our company was a licensee in good standing with the State of New Jersey under R. S. 54:39-1 et seq. Our filings and payments

were made accurately and timely.

— OR —

Our company meets the financial responsibility or bonding requirements set forth by the Motor Fuels Tax Act of 2010.

We agree that in order to enable our Suppliers to meet their obligations to the State of New Jersey, we MUST remit the amount of tax due

to our Suppliers by EFT no later than the 20

day of the month following the taxable event.

Based on the above acknowledgment, affirmation, and agreement, we request that the State of New Jersey recognize us as a Qualified

Distributor pursuant to R. S. 54:39-101 et seq. We are qualified to delay remittance to our Suppliers of tax due until the 20

day of the month

following the taxable event. We recognize that our company, and not our Suppliers, will be liable for penalties and interest in the event that we make

remittance to our Suppliers late. We further recognize that a late remittance to our Suppliers will revoke our status as a Qualified Distributor.

QUALIFIED DISTRIBUTOR APPLICATION must be signed by an authorized representative of the company as listed in

Section 5 of this application.

Signature

Title

Printed Name

Date Signed

Section 17 – Authorizing Signature

Under penalty of perjury, my signature affirms all of the following:

 The information provided in this application, to include all attachments, is accurate and complete to the best of my knowledge.

 The applicant agrees to provide accurate and timely reports and to make timely payments.

Inaccurate or incomplete information in any section is cause for denial of the requests made in Section 15 or 16, and/or the denial of