Form Mf-10 - Application For Special Pre-Paid Lp-Gas User Permits And Decals - Kansas Department Of Revenue

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Val. No.
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-8000
Phone Number: (785) 368-8222
Fax: (785) 296-4993
APPLICATION FOR SPECIAL PRE-PAID LP-GAS USER
PERMITS AND DECALS
Permit No.
(Office Use)
FEDERAL EMPLOYEE IDENTIFICATION
NUMBER OR SOCIAL SECURITY
NUMBER:
DAY TIME TELEPHONE:
The vehicle information below is what is currently reflected on your account. Feel free to make necessary
changes or corrections in the information. Complete those columns which are blank. If you no longer have
one of the vehicles listed please mark through its information. Any new vehicles which you have acquired
should be added in the blank spaces. Apply the applicable fees according to the tax schedule reflected on
the reverse side. Enclose one check made payable to the Director of Taxation.
Previous Years
Current
Vehicle
Number of Miles
Ending Odometer
Odometer
Weight
Identification
Operated
Fee
Reading
Reading
Year
MAKE
Class
Number
Last Year
Amount
TOTAL AMOUNT OF FEES ENCLOSED
$
Applicant hereby states that the above application and all statements contained therein, are true and correct.
Signature of Owner, Partner or Corporate Officer (Circle One)
Date
SEE REVERSE SIDE FOR TAX SCHEDULE
MF-10
(Rev. 4/04)

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