Dr-156t - Florida Temporary Fuel Tax Application Page 5
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5DR-156T
R. 01/16
Page 3
13.
Carrier Information
A) Do you transport petroleum products/fuels
over the highways and/or waterways of Florida? .............
YES ...........
NO
If “YES,” are you a common carrier? ................................
YES ...........
NO .......................... If “NO,” go to question 13(B)
If “YES,” what mode of transportation
is used to transport the fuel/petroleum products?
Truck
Rail
Vessel
Pipeline
B) If you are not a common carrier, list the make/model, year, vehicle identification number, and total tanker capacity of each
truck, barge, boat, or other equipment used to transport fuel on the highways or waterways of Florida. Cab cards will be
issued for each motor vehicle or item of equipment used to transport fuel. (If necessary, attach a separate sheet.)
Make/Model
Year
Vehicle ID Number
Tanker Capacity (in Gallons)
14.
Pollutants Storage Information
Will this business import pollutants into this state? ..............
YES ...........
NO
Licensing Information
15.
Are you registered to collect and/or remit sales tax? ..................................................................................... YES
NO
16.
Will this business import fuels into Florida upon which there has been no precollection of Florida tax? ...... YES
NO
17. Do you transport petroleum products either for yourself or for hire? ............................................................. YES
NO
18. Do you export fuels from this state other than by pipeline or marine vessel? ................................................ YES
NO
19. Do you have a fuel license issued by another state? ...................................................................................... YES
NO
IF yes, please provide the state and license number. State ________________ License Number _______________________
Affidavit of Applicant(s)
I, the undersigned individual(s), or if a corporation for itself, its officers, and directors, hereby swear or affirm under penalty of
perjury as provided in section 837.06, Florida Statutes, that I am duly authorized to make the foregoing application and that the
application and all attachments are true and correct representation(s) of the premises to be licensed. If licensed, I agree that the
place of business may be inspected and searched, during business hours or at any time business is being conducted on the
premises, by officials and agents of the Department of Revenue for the purposes of determining compliance with Chapter 206, F.S.
Sworn to (or affirmed) and subscribed before me
this ____________ day of ___________________ , ____________ .
State of _____________ County of ________________________________
__________________________________________
_________________________________________________________
Signature of Notary Public
Signature of Applicant
_________________________________________________________
Print or Type Applicant’s Name
__________________________________________
W A R N I N G :
Print, Type or Stamp Name of Notary
Personally Known __________
or Produced Identification __________
Read carefully: This instrument is a sworn document. False answers
Type of Identification Produced ___________________________________
could result in criminal prosecution subject to fine and/or imprisonment
and denial of your application.
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