Form Pet 367 - Application And Permit For Production Of Fuel Alcohol

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PET

TENNESSEE DEPARTMENT OF REVENUE

367

APPLICATION AND PERMIT FOR PRODUCTION OF FUEL ALCOHOL

See general registration information on the back of this application. For additional information regarding this application you may call Taxpayer Services

between 8 a.m. and 4:30 p.m. (CT), Monday through Friday, holidays excepted. Please see the back of this notice for local offices and phone numbers.

NAME AND EXACT LOCATION

BUSINESS MAILING ADDRESS

NAME (Give trade name at this location)

NAME (Enter corporation name if applicable)

Street, Highway, Community (Do not use P.O. Box #)

Street, or Route, P.O. Box #

City

County

State

ZIP Code

City

State

ZIP CODE

City and state where business records are to be located

Business telephone number

5. Type of Ownership:

Proprietorship

Partnership

Corporation

Limited Liability Company

SSN ____________________________________

FEIN ___________________________________

6. Identify owners, officers, or partners

Name ___________________________________________________

Name _______________________________________________________

Address ________________________________________________

Address ____________________________________________________

City, State, ZIP Code _______________________________________

City, State, ZIP Code ___________________________________________

_______________________________________________________

____________________________________________________________

Phone No. _______________________________________________

Phone No. ___________________________________________________

7. Is this fuel solely for your own use?

Yes

No If No, explain: ___________________________________________________________________

____________________________________________________________________________________________________________________________

8. Estimated quantity of fuel alcohol to be produced annually.

________________________________________________ Gallons

9. Estimated quantity to be sold to others.

________________________________________________ Gallons

Production

Fee Required

Fee Paid

1. 1-999 Gallons ............................................................... $0.00 ..........................................................

$ ___________________________

2. 1,000-2,500 Gallons .................................................. $50.00 ..........................................................

$ ___________________________

3. Over 2,500 Gallons ................................................... $100.00 ..........................................................

$ ___________________________

4. Total Fee ............................................................................................................................................

$ ___________________________

In accordance with T.C.A. Section 60-4-101 and 102, I hereby apply for permission

FOR OFFICE

to produce fuel alcohol and I enclose $ ________________________________

USE ONLY

as an annual license fee, required to produce such estimated quantity shown. Should

my production exceed limitations imposed, I will remit additional fee without request.

SIGN

HERE _______________________________________________________

RV-R0008201

INTERNET (5-05)