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Form Mf-42 - Application For Motor Vehicle Fuel And Special Fuel Distributor'S License Page 2

19. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of a felony

Yes

involving theft within 5 years immediately preceding the date of making application in this or any other jurisdiction?

felony

20. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of a

involving fraud or tax evasion in this or any other jurisdiction?

Yes

21. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock had a motor fuel license

revoked for cause in another state?

Yes

22. Do you or any partner, corporate officer or stockholder owning more than 5% of company stock intend to carry on the business

authorized by the license as agent of another?

Yes

23. If you answered yes to any question 18-22, please explain on a separate sheet of paper.

State of

County of

, ss:

, first being fully sworn, state that the above application, and all

statements contained therein, are true and correct under the penalty of perjury.

(Signature of Owner, Partner, Corporate Officer, or Person Authorized by a Power of Attorney)

(Title)

Subscribed and sworn to before me, this

day of

My commission expires

(Notary Public)

INSTRUCTIONS

This application is to be completely and properly executed and must be supported by a Motor Vehicle

Fuel and Special Fuel Distributor's Bond and Financial Statement (MF-43). Articles of Organization

or Incorporation are also required if the ownership type is LLC.

1. The Motor Vehicle Fuel and Special Fuel Distributor's Bond is required for all new applicants, in

the amount of $1,000.00 or 3 months tax liability, which ever is greater.

2. If you need to add a location after your license has been issued, a separate application must be

filed.

3. No fee is required for this license.

4. You must report any change in ownership, including a change in partners, corporate officers or

stockholders who own more than 5% of company stock within 30 days of the change.

This completed application or inquiries concerning this application should be directed to:

KANSAS DEPARTMENT OF REVENUE

CUSTOMER RELATIONS

MOTOR FUEL TAX

915 SW HARRISON ST

TOPEKA, KANSAS 66625-8000

PHONE: (785) 368-8222

FAX:

(785) 296-4993

Form Mf-42 - Application For Motor Vehicle Fuel And Special Fuel Distributor'S License Page 2

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