Form Fut-6 - Application For Fuel Use Permit 2003 printable pdf download

FUT-6

Rev. 10/03

Excise and Motor Fuel Division

P.O. Box 530

Columbus, OH 43216-0530

(614) 466-3921

Fax (614) 728-8085

Applications not completed in accordance with these instructions will be returned (please print or type).

1. If you are an individual, enter your last, first and middle

on line 2 below within two working days of receipt of this

name. If partnership, enter the full name of the partners.

application at the above address.

If incorporated, enter corporate name.

7. Indicate if all of your vehicles are farm plated.

2. Enter your legal address.

8. OPTIONAL – If you need immediate authority to run, check

3. Enter both telephone number and fax number.

“yes” to have a temporary authority faxed to you at the fax

number listed on line 3.

4. If you are an individual, enter your social security number.

If partnership, enter social security numbers of all partners.

8A. Enter vehicle identification number upon receipt of

If incorporated, LLC, LP or LLP, enter federal employer

validated temporary authority. Note: You may reproduce

identification number.

a validated temporary authority for up to the number of

permits requested on line 6. A temporary authority is valid

5. Check only one box.

for 30 days.

6. Enter the number of sets of permits needed. Order only

9. Sign and date application.

as many as needed. You are required to account for every

permit issued to you for the current year and the previous

10.Ohio Department of Taxation validation stamp.

three years. Permits will be mailed to the address listed

Federal Privacy Act

Because we are requesting your social security account

need your social security number in order to administer this

number, the Federal Privacy Act of 1974 requires us to

tax. Your failure to supply any information requested on a

inform you that your providing us your social security number

tax form prescribed by the Tax Commissioner may result in

is mandatory. Ohio Revised Code sections 5703.05 and

the imposition of penalties for failing to file a complete tax

5747.08 authorize our asking you for this information. We

return or the denial of a license application, if applicable.

Telephone: (614) 466-3921 Fax: (614) 728-8085

Account number

Application for Fuel Use Permit

1. Name

Last

First

Middle

2. Legal address

Street

City

State

ZIP code

3. Telephone number

Fax number

Social security number

Federal employer identification number

Individual

Partnership

Corporation

LLC

LLP

Other

6. Number of permits needed

7. Are all of these vehicles farm plated?

Yes

8. For Temporary Authority Use Only

Do you wish to have a temporary authority faxed to you?

Yes

10. Temporary Permit Not Valid

Unless Stamped

8A. Vehicle identification number

I declare under the penalties of perjury that this application (including any

accompanying statements) has been examined by me and to the best of my

knowledge and belief is a true, correct, and complete application.

Signature

Date

Form Fut-6 - Application For Fuel Use Permit 2003

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