Form Mf-51 - Application For Motor Vehicle/special Fuel Tax Refund Permit
ADVERTISEMENT
1
2Permit # ________________
Date Issued _____________
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
915 SW HARRISON ST.
CHECK HERE TO INDICATE
TOPEKA, KANSAS 66625-8100
AN ADDRESS CHANGE ______
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 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)__________________________________________________________________ County:__________________
Custom Work Performed? ___(Y/N)
Acres Owned or Leased ________________________________
Refrigeration: (Describe)__________________________________________________________________________________________
Other: (Describe)________________________________________________________________________________________________
9.
Do you have a current IFTA license? ___(Y/N)
If yes, what is your base jurisdiction? __________________________
10. List Tractors, Stationary Engines and Other Gas and Diesel Equipment
11.
List Cars and Trucks Owned by Applicant
MAKE
MODEL
FUEL TYPE
MAKE
MODEL
FUEL TYPE
_______________________________________________________
___________________________________________
_______________________________________________________
___________________________________________
_______________________________________________________
___________________________________________
_______________________________________________________
___________________________________________
12.
Bulk Fuel Storage (In Gallons)
Gasoline-Highway
Gasoline-Non Highway
Diesel-Highway
Diesel-Non Highway
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
$6.00
Enclose a
Check or Money Order Payable to: “Kansas Department of Revenue”
MF-51 (Rev. 04/04)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mf-169 - Application For Motor Vehicle Fuel And Special Fuel Producer/manufacturer, Blender, End Consumer
Financial
Form Mf-44 - Application For Motor Vehicle Fuel And Special Fuel Importer/exporter License
Financial
Related Categories
Parent category: Financial