Form Mf 100a - Fuel Tax License Application

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SD EForm - 0824
V4
HELP
Department of Revenue
Division of Motor Vehicles - Fuel Tax License Application
Return signed application to: Division of Motor Vehicles, Fuel Tax Licensing, 445 East Capitol Ave, Pierre SD 57501-3185
Please print in black ink or type. Do not write in shaded areas.
License Number issued:
Date Issued:
County Code:
Taxpayer Business Information
Instructions: All of the following blanks must be completed for all license applications. A post office box number is not an acceptable ad-
dress for your physical location; you must furnish the street address or rural route number. A post office box number is an acceptable mail-
ing address. The information below applies to the license applicant only. Reporting services or accounting firms see accounting section.
Owner, Partner or Corporation Name
Doing Business As Name (DBA) if different than noted above
Federal EIN Number
Business Phone Number
Fax Number
Physical Location (street address)
City
State
Zip
Mailing Location (if different than physical location)
City
State
Zip
If you have a separate address within your company that you prefer your tax return information be forwarded to, or if you wish the infor-
mation be sent to the attention of, please provide this information.
Attention of
E-Mail
Tax Return Mailing Address if different than above (street)
City
State
Zip
Phone Number
Accounting Information
Reporting Services or Accounting Firms: If you wish to utilize a firm to complete your tax returns please complete a Department of Rev-
enue power of attorney form. Once this is completed and returned, all tax returns and any notices will be mailed to the firm’s address.
Ownership Type
Check one:
Single ownership
Informal partnership (verbal agreement between partners)
Formal Partnership (written agreement between partners)
Corporation: State of incorporation
Date of incorporation
If not South Dakota, indicate date of registration with South Dakota Secretary of State
Limited liability company
Trust
Other (List)
If you have questions concerning this application please call 605-773-5335.
MF 100A 06-09

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