Form Mf 100a - Fuel Tax License Application Page 4
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SU – Supplier: Any person that owns motor fuel or special fuel in the pipeline and terminal distribution system in this state and makes
sales or authorizes the removal of this fuel from the terminal at the rack. A Supplier is also the person who owns fuel in the pipeline imme-
diately before it is withdrawn at the terminal rack. Please list the terminals from which you are operating in South Dakota. Attach addi-
tional sheets if necessary. This is a mandatory license.
Name
Telephone Number
Address
City
State
Zip
Any person meeting the definition of a Supplier as listed above and operating from a terminal located outside of South Dakota may volun-
tarily become licensed as a Supplier. Please list the terminals you are operating outside of South Dakota. Attach additional sheets if neces-
sary. This is a voluntary license.
Name
Telephone Number
Address
City
State
Zip
TO - Terminal Operator: A person that by ownership or contractual agreement is charged with the responsibility and physical control
over the operation of a terminal. A Terminal is a fuel refinery or storage and distribution facility that is supplied by pipeline or marine
vessel, from which motor fuel or special fuel may be removed at a rack and that has been registered as a qualified terminal by the Internal
Revenue Service. Terminal Operators must be licensed to do business in South Dakota. A separate license is required for each terminal
location.
1.
Name
Physical Address
City
State
Zip
IRS Control #
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
2.
Name
Physical Address
City
State
Zip
IRS Control#
Mailing address if different than physical
City
State
Zip
Phone #
Fax #
TR – Transporter: A person that moves fuel within South Dakota or to areas outside this state by transport truck, rail car or other
means in quantities greater than 4,200 gallons. Transport trucks are defined as vehicles or rail cars designed to transport bulk fuel ship-
ments in excess of 4,200 gallons.
Important Notice - Please Read
Please complete this form in its entirety. Failure to provide the requested information is grounds for license denial. If the applicant is a cor-
poration, or if the applicant is a limited liability company or trust, the undersigned acknowledge and agree that they are personally liable for
filing returns and payment of taxes resulting from the operation of the company or trust. As provided in Section 7(b) of the Federal Privacy
Act of 1974, Public Law 93-579, you are informed that the social security number is a mandatory request pursuant to SDCL 10-47B-71 and
that it will be used as an identification number for file control and record keeping purposes and for possible cross-checking with the Internal
Revenue Service.
THIS APPLICATION MUST BE SIGNED by the owner, by all partners or in case of corporation, an executive officer. An authorized
person may sign for a partnership or a corporation if proof of authorization is attached to the application. Attach additional sheets for signa-
tures if necessary. A new form must be completed when any changes occur in owners, partners or corporate officers.
I hereby certify, as owner/operator of this business that all information provided is true and correct to the best of my knowledge
and belief. Permission is also, hereby, granted to the Department of Revenue to release the status of this license (either active,
canceled or in arrears) to affected parties.
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