Form Sft-1- License Application - Massachusetts Department Of Revenue

Form Sft-1- License Application - Massachusetts Department Of Revenue - 2013 Page 2

EFFECTIVE DATE

VALIDATION NUMBER

DO NOT WRITE IN SPACES ABOVE

THE COMMONWEALTH OF MASSACHUSETTS

THE FEE FOR A USER-SELLER OF SPECIAL FUELS LICENSE OR A

DEPARTMENT OF REVENUE

SUPPLIER OF SPECIAL FUELS LICENSE IS $25.00. MAKE CHECK OR

MONEY ORDER PAYABLE TO "COMMONWEALTH OF MASSACHUSETTS".

2013

DO NOT COMBINE THE LICENSE FEE WITH ANY OTHER FEE OR

PAYMENT.

FORM SFT-1 - LICENSE APPLICATION

USER-SELLER OF SPECIAL FUELS

SUPPLIER OF SPECIAL FUELS

(617) 887-5040

FOR INFORMATION TELEPHONE

1. F.I.D. OR SOCIAL SECURITY NUMBER

BUSINESS ADDRESS. TYPE OR PRINT ALL ENTRIES

2. NAME OF LICENSEE

3. NAME (CONTINUED)

4. BUSINESS ADDRESS (STREET AND NUMBER)

5. CITY OR TOWN

6. STATE

7. ZIP CODE

8. AREA CODE / TELEPHONE NUMBER

MAILING ADDRESS

9. MAILING ADDRESS (STREET AND NUMBER)

10. CITY OR TOWN

11. STATE

12. ZIP CODE

13. AREA CODE / TELEPHONE NUMBER

If now licensed, apply for renewal of the same type of license, unless the

INSTRUCTIONS

nature of the business has changed or otherwise instructed by Commissioner.

A "USER-SELLER"

is any person, not licensed as a Supplier, who dispenses special fuel into the tanks

of motor vehicles. User-sellers may not resell special fuel in bulk.

User-sellers pay MA fuels excise

at the time of purchase.

A "SUPPLIER"

is any person who sells or delivers special fuels to a User-Seller and any person who

imports special fuels and resells or uses the same in a motor vehicle. Suppliers pay MA fuels excise

with their monthly return.

The undersigned hereby makes application under the provisions of the General Laws, Chapter 62C, for a

2013

license for

as a:

CHECK ONE ONLY:

USER-SELLER OF SPECIAL FUELS

SUPPLIER OF SPECIAL FUELS

and agrees to file tax returns and such other information required and pay the tax due on special fuels

sold or used in Massachusetts in compliance with Chapters 62C and 64E of the General laws. The

undersigned also certifies, under the penalties of perjury, that all of the information contained in

this application is true, accurate and complete and that he/she has complied with all laws of the

Commonwealth relating to taxes.

SIGN HERE

DATE

TITLE

APPLICANTS MUST COMPLETE REVERSE SIDE OR APPLICATION WILL BE RETURNED.

MAIL TO: MASSACHUSETTS DEPARTMENT OF REVENUE , P .O. BOX 7012, BOSTON, MA 02204

Form Sft-1- License Application - Massachusetts Department Of Revenue - 2013 Page 2

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