Application For Florida Motor Fuel Use Tax (Fut) Page 2
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216. Indicate with a check (2) the jurisdictions in which you are operating, and in which you maintain bulk fuel storage
IF = Bulk Fuel Storage)
(OP = Operate
OP
BF
Jurisdiction
OP
BF
Jurisdiction
OP
Jurisdiction
OP
BF
Jurisdiction
BF
AL
Alabama
KY Kentucky
NC N. Carolina
WI Wisconsin
LA Louisiana
AK
Alaska
ND N. Dakota
WY Wyoming
AZ
Arizona
ME Maine
OH Ohio
CANADIAN
PROVINCES
AR
Arkansas
MD Maryland
OK Oklahoma
CA
California
MA Massachusetts
OR Oregon
AB Alberta
Co
Colorado
MI Michigan
PA
BC Br. Columbia
Pennsylvania
CT
Connecticut
MN Minnesota
RI
Rhode Island
MB Manitoba
DE
Delaware
MS Mississippi
SC
S. Carolina
NB New Brunswick
DC
Dist. of Col.
MO Missouri
SD
S. Dakota
NF Newfoundland
Florida
FL
MT Montana
TN Tennessee
NS Nova Scotia
GA
Georgia
NE Nebraska
TX Texas
NT Northwest Territ.
ON Ontario
ID
Idaho
NV Nevada
UT Utah
IL
Illinois
NH New Hampshire
VT Vermont
PE Prince Edward Is.
NJ New Jersey
VA Virginia
PQ Quebec
IN
Indiana
WA Washington
SK
Saskatchewan
IA
Iowa
NM New Mexico
WV West Virginia
YT
Yukon
KS
Kansas
NY New York
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS APPLICATION AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS
CORRECT AND COMPLETE. I AGREE TO COMPLY WITH REPORTING, PAYMENT, RECORD-KEEPING AND LICENSE DISPLAY REQUIREMENTS AS SPECIFIED
IN THE INTERNATIONAL FUEL TAX AGREEMENT. J FURTHER AGREE THAT THE FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
MAY WITHHOLD ANY REFUNDS DUE ME IF I AM DELIQUENT ON PAYMENT OF FUEL TAXES DUE ANY MEMBER JURISDICTION. I UNDERSTAND THAT
FAILURE TO COMPLY WITH THESE PROVISIONS SHALL BE GROUNDS FOR REVOCATION OF MY LICENSE IN ALL MEMBER STATES.
Date
Telephone Number
Signature of Owner, Partner, Corporate Officer or Person Authorized
by Attached Power of Attorney
INSTRUCTIONS
(Please Print or Type Application)
1a. OWNER'S NAME - Print the name of the person making application. b. Print the name of the business, if different.
2. BUSINESS LOCATION - Enter the actual location of your motor carrier business or office.
3. MAILING ADDRESS - Enter the location where credentials should be mailed.
4. CONTACT PERSON - Enter name of person to contact in reference to account.
5. TELEPHONE NUMBER - Enter contact person's telephone number.
6. ACCOUNT NUMBER - List your FEI # or the Social Security # of an officer of the company if the company does not have an FEI number.
number should be referenced when inquiring on your account.
This
7. TELEPHONE NUMBER - Enter your business telephone number.
8. TYPE OF OWNERSHIP - Check the box that best describes your type of ownership.
9. OWNER'S NAME - Print the name of the owner of the above motor carrier business (if same, please indicate)
10. If you are registered with the Florida Department of Revenue under Chapter 206, Florida Statutes, as a Special Fuel Dealer Distributor, please
give license numbers of both, and the date the license was issued (effective).
I 1. FLORIDA IRP ACCOUNT NUMBER - Enter Florida IRP account number.
12. Indicate with a check (2) the types of fuel. used, (check all that apply).
13. Indicate with a check (2) whether you have ever been licensed as an IFTA carrier in another IFTA jurisdiction.
14. If you were previously licensed, indicate with a check (2) whether your license was ever revoked.
15. Indicate the number of IFTA / FUT decals or Drive-A-Ways needed.
16. SCHEDULE OF IFTA JURISDICTIONS - Place a check (2) next to each jurisdiction in which you plan to operate and maintain bulk storage.
NOTE: Drive-A-Way permits are issued to FUT applicants only. An IFTA carrier conducting a Drive-A-Way operation must order an IFTA decal.
Reset
HSMV 85008 (Rev. 1/96) S
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