Fillable Form Pet 365 - Liquified Gas User Addendum printable pdf download

TENNESSEE DEPARTMENT OF REVENUE

500 DEADERICK STREET

ANDREW JACKSON STATE OFFICE BUILDING

NASHVILLE, TN 37242

PET

LIQUIFIED GAS USER ADDENDUM

365

Please complete the front and back of the addendum and return it to this office with the appropriate remittance as shown on the

bottom of this notice. All questions must be answered completely for your addendum to be processed.

For additional information, contact the Taxpayer Services Division in Nashville by calling our statewide toll free number at 1-800-342-

1003. Out-of-state callers dial (615) 253-0600. The office is located on the 3rd Floor of the Andrew Jackson State Office Building at

500 Deaderick Street, Nashville, TN 37242.

For the period July, _______ through June, _________

Check the appropriate block below. If you are adding decals, also include your account number in the space provided.

New Registration and Decals

For Additional Decals Only

Account No. ________________________

MAILING ADDRESS

NAME AND EXACT LOCATION

NAME (GIVE TRADE NAME AT THIS LOCATION)

STREET OR ROUTE, P.O. BOX #

STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

CITY

COUNTY

STATE

ZIP CODE

Area Code (

)

For what purposes will your vehicles be used?

Private

Commercial

Will all commercial vehicles which you register be used solely within the State of Tennessee?

Yes

COMPUTATION OF FEES

(Complete schedule on reverse side and transfer total to the appropriate line below)

1. ANNUAL FEES (Schedule Total from Part I on back of return) .................................... $ _________________

2. PRORATED FEES (Schedule Total from Part II on back of return) ................................ $ _________________

3. TOTAL FEES AMOUNT (Add lines 1 and 2) .............................................................. $ _________________

Make Check Payable to:

FOR OFFICE USE ONLY

Tennessee Department of Revenue

In accordance with Tennessee Code Annotated Title 67, Chapter 3, Part 22, I hereby

Retain a copy of this addendum to serve

tender payment for tax on my liquified gas licensed vehicles. I certify that I do not own,

lease, or regularly operate any licensed liquified gas vehicle other than those repre-

as a 30-day temporary permit to allow the

MAIL TO:

sented on this addendum or bearing a current decal.

applicant to purchase liquified gas tax ex-

TENNESSEE DEPARTMENT

(ADDENDUM MUST BE SIGNED)

OF REVENUE

empt from a qualified dealer. However, if

SIGN

Andrew Jackson State

the applicant is not granted a permit within

HERE ________________________________________________

Office Bldg.

the 30-day period, the dealer shall be li-

SIGNATURE OF PERSON SUBMITTING THIS ADDENDUM

Nashville, TN 37242-0500

able for the tax imposed.

________________________________________________________________

TITLE

CORPORATE OFFICER, AGENT, ETC.

DATE

INTERNET (2-04)

RV-R0007801

Form Pet 365 - Liquified Gas User Addendum

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