Form Mf-400 - Kansas Qualified Agricultural Ethyl Alcohol Producer Incentive Fund - Kansas Department Of Revenue
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1
2KANSAS DEPARTMENT OF REVENUE
FOR OFFICE USE ONLY
CUSTOMER RELATIONS
915 SW HARRISON ST.
DATE RECEIVED _________
TOPEKA, KANSAS 66612-1588
DATE APPROVED ________
Phone Number: (785) 368-8222
Fax: (785) 296-2703
KANSAS QUALIFIED AGRICULTURAL ETHYL ALCOHOL PRODUCER INCENTIVE FUND
1.
Legal Name:
2.
DBA Name:
3.
Business Mailing Address:
Street Address or Post Office Box
City
State
Zip Code
4
List the exact location of the place in Kansas where applicant intends to produce agricultural ethyl alcohol:
.
Address
City
County
State
Zip Code
5.
Indicate whether location is owned or leased by applicant:
6.
Federal Employers Identification Number:
6.
Business Phone Number:
Fax Number :
7.
Check Type of Ownership:
Individual
Partnership
Corporation
Other
8.
List Owner, Partners or Corporate Officers (Attach list of additional partners and corporate officers):
TELEPHONE
NAME
ADDRESS
TITLE
NUMBER
9.
Name and telephone number of a contact person for producers report inquires:
Name
Telephone Number
10.
ATF Permit Number:
11. Plant production capacity:
12.
Type of Production Plant:
Grain Ethanol Based Production
Cellulosic Ethanol Based Production
13.
Materials to be used in the production of Grain Ethanol (Check all boxed that apply).
‰
Grain (Corn, wheat, sorghum, barley, etc.) and other starch products (potatoes, sweet potatoes, etc.).
‰
Sugar based crops (cane sugar, sugar beets, molasses, sweet sorghum, beef fodder, etc.).
‰
Fruits or fruit products (Grapes, peaches, apples, etc).
‰
Other (Describe)
14.
Materials to be used in the production of Cellulosic Ethanol
‰
Forage crops (Alfalfa, switch grass, sudan grass, forage sorghum, etc.).
‰
Crop residue (Garbage or other refuse).
‰
Other (Describe) _______________________________________________________________________________________________
15.
Production start date: ______________________________________________________________
16.
Conditions:
Applicant has made no false statements as to any material fact in this application.
Applicant has complied with all State and Federal laws.
All persons employed by applicant in good faith agree to observe and conform to all of the terms and conditions.
STATE OF _______________________________________ )
) SS:
COUNTY OF_____________________________________ )
I, ___________________________________________________ first being fully sworn, state that the above application and all statements and
conditions contained therein, are true and correct.
_____________________________________________ ___________________
Signature
Title
Subscribed and sworn to before me, this _________ day of _________________________________________, 20______
My commission expires __________________________ 20 __________ _____________________________________
Notary Public
MF-400
Rev. 6/13)
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