Form Ar-1r - Combined Business Tax Registration Form Page 4
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7SECTION I - CORPORATE INCOME (INCLUDING SUB S ELECTION)
31.
a) Date Activity Begins in AR
b) DBA (if applicable)
a) Mailing Address (if different from Section B)
b) City
c) State
d) Zip Code
32.
For Sub S Election please complete and attach form AR1103.
SECTION J - PARTNERSHIP INCOME
33.
a) Date Activity Begins in AR
b) DBA (if applicable)
a) Mailing Address (if different from Section B)
b) City
c) State
d) Zip Code
34.
SECTION K - MOTOR FUEL
a) Date to start purchasing or importing Fuel into Arkansas:
b) DUNS Number:
35.
c) DBA (if applicable)
a) Mailing Address (if different from Section B)
b) City
c) State
d) Zip Code
36.
Please check the Fuel Type you plan to import or purchase for resale or distribution in Arkansas.
37.
Gasoline
Distillate Special Fuels
Liquefied Gas
Natural Gas
If importing or exporting Fuel, what means of Transport will you utilize?
38.
Truck
Rail
Barge
Pipeline
39.
Do you transport petroleum in any device having a carrying capacity exceeding 9,500 gallons?
Yes
No
40.
a) Have you previously held a Motor Fuel Tax License in Arkansas?
Yes
No
b) License Number
41.
Are you acquiring an existing business that held a Motor Fuel Tax License?
Yes
No
42.
a) Company Name
b) Account Number
43.
Do you have Bulk Storage Facilities in Arkansas?
Yes
No
44.
Estimate the number of gallons to be reported in the State of Arkansas each month.
a) Gasoline
b) Diesel
If you are granted a License, do you expect to:
Import Fuel into Arkansas?
Have any Transactions in Dyed Petroleum Products?
Sell Fuel to other Arkansas Licensed Distributors?
45.
Export Fuel from Arkansas?
Take Ownership of Fuel at an Arkansas Terminal?
Sell Fuel to Non-Licensed Reseller or Consumer?
Blend Gasoline or Diesel Fuel with Alcohol or Ethanol, other Petroleum Products, Agricultural or Waste of such Products?
SECTION L - DYED DIESEL
46.
a) Date Activity Begins in AR
b) DBA (if applicable)
a) Mailing Address (if different from Section B)
b) City
c) State
d) Zip Code
47.
SECTION M - BRINE SEVERANCE
48.
a) Date Activity Begins in AR
b) DBA (if applicable)
49.
Please check the applicable classification.
Purchaser
Producer
a) Mailing Address (if different from Section B)
b) City
c) State
d) Zip Code
50.
SECTION N - NATURAL GAS SEVERANCE
a) Date Activity Begins in AR
b) DBA (if applicable)
51.
c) Please check the applicable classification.
Purchaser
Producer
d) AR Oil/Gas Commission Operator Number (if applicable):
a) Mailing Address (if different from Section B)
b) City
c) State
d) Zip Code
52.
Revised 08/10/2012
Page 4 of 7
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