Form Mf-51 - Application For Motor Vehicle/special Fuel Tax Refund Permit

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KANSAS DEPARTMENT OF REVENUE

Permit # ________________

CUSTOMER RELATIONS

915 SW HARRISON ST.

Date Issued _____________

TOPEKA, KANSAS 66612-1588

Phone Number: (785) 368-8222

Fax: (785) 296-2703

APPLICATION FOR MOTOR VEHICLE/SPECIAL FUEL TAX REFUND PERMIT

1. Name of Applicant __________________________________________________________________________________________________

2. Mailing Address ____________________________________________________________________________________________________

Street Address or Post Office Box

City

State

Zip Code

3. Location Address ___________________________________________________________________________________________________

Address

City

County

State

Zip Code

4. FEIN Number/Social Security Number __________________________

5. Telephone Number ______________________________

6. Check Type of Ownership:

Individual

Partnership

Corporation

School District

Other ________________________

7. List Individual, Owner, Partner, or Corporate Officers:

NAME

ADDRESS

SOCIAL SECURITY NUMBER

TITLE

PHONE NUMBER

__________________________________________________________________________________________________________________

8. Specific Use of Tax Refund Fuel:

PTO Usage: (Describe)____________________________________________________________________________

_______________

A flat percentage may not be claimed unless this percentage was arrived at using one of the following methods: Use of on board computers to monitor

fuel usage or a sample test period conducted of equipment used by your company.

Agricultural: (Describe)_______________________________________________________________Acres Owned or Leased___

Refrigeration: (Describe)______________________________________________________________________________________

Federal Government Agencies: (Describe)______________________________________________________________________________________

Buses (Describe)________________________________________

Only allowed for transportation of students to and from school related activities.

Other: (Describe)________________________________________________________________________________________________

9. Do you have a current International Fuel Tax Agreement (IFTA) license? ___(Y/N) If yes, what is your base jurisdiction?

10. List ALL Tractors, Stationary Engines and Other Gas and Diesel Equipment

11.

List ALL Cars and Trucks Owned by Applicant

MAKE

MODEL

FUEL TYPE

MAKE

MODEL

FUEL TYPE

12. Bulk Fuel Storage (In Gallons and fuel type Highway/Non Highway i.e., 500 Gas, 300 Gasohol, E-85 200, Diesel 100)

Fuel Type Highway _________

Fuel Type Non Highway ________

Fuel Type Highway __________

Fuel Type Non Highway _______

13. Kansas Retailers’ Sales Tax Number

(For more information refer to the back of the application.)

Applicant agrees to comply with all provisions of the Motor Vehicle/Special Fuel Tax Refund Law and Regulations and to maintain adequate records

to support all claims submitted for a refund of the motor fuel taxes. Adequate records include fuel purchase documents and fuel usage records as

detailed in the motor fuel statute. Upon receipt of the motor fuel tax refund, applicant understands that the fuel purchases may be subject to sales tax.

I certify that I have read the foregoing and that all statements contained in this application are true and correct.

Sign Here

Signature of Owner, Partner, Corporate Officer, or Person Authorized by Attached Power of Attorney

Date

Telephone Number

Title

$6.00

Enclose a

Check or Money Order Payable to: “Kansas Department of Revenue”

MF-51 (Rev. 6/13)