Form 72a005 - Application For Approval To Sell Watercraft Refund Motor Fuels
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1APPLICATION FOR APPROVAL
72A005 (4-09)
TO SELL WATERCRAFT REFUND MOTOR FUELS
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
Public Boat Dock
Pursuant to Kentucky Revised Statute 138.445, a refund of Kentucky tax may be obtained on gasoline or diesel fuel purchased to be sold
for use in operating watercraft. The applicant must, however, operate a public boat dock, approved by the Department of Revenue, to be
entitled to a refund.
Name of Business (enter exact business name)
Mailing Address
P.O. Box or Number and Street
City or Town
State
ZIP Code
(
)
Telephone (daytime)
E-mail Address
Location of Business
Number and Street or Highway
City or Town
County and State
Name of Stream, River or Lake
1. Indicate type of ownership
Individual
Partnership
Corporation
Other (describe)
2. Give the name of previous owner(s), if any
3. Describe the location of the dispensing units in relation to ramp or docking facilities
4. Can automobiles be fueled from these facilities?
Yes
No
5. Do you sell gasoline or diesel fuel at this location for purposes other than use in watercraft?
Yes
No
If yes, explain
6. Are the storage facilities (if above ground) and the dispensing facilities marked “Not For Highway Use,” in letters at least two inches
in height, and of a color in contrast to that of the storage facility?
Yes
No
7. Give the names and addresses of your primary and secondary suppliers of watercraft refund motor fuels.
Primary Supplier
Secondary Supplier
COMPLETE IF INDIVIDUAL OWNERSHIP
COMPLETE IF CORPORATION
Name of Owner
Social Security No.
Name of Corporation
FEIN
Driver’s License No.
Corporate Officers
Social Security No.
COMPLETE IF PARTNERSHIP
Name of Owner
Social Security No.
Driver’s License No.
Name of Owner
Social Security No.
(Attach list if necessary.)
Driver’s License No.
CERTIFICATION
The above statements are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly authorized to sign this application.
Signed
Title
Date
(Signature of owner or partner. If a corporation, an officer must sign.)
This application must be prepared in duplicate and both copies sent to the Motor Fuels Tax Compliance Section, Division of Miscellaneous
Taxes, Department of Revenue, P.O. Box 1303, Frankfort, Kentucky 40602-1303. One copy will be returned to the applicant. If the
location is approved, the applicant’s copy must be kept on file as his authority to sell watercraft refund motor fuels. Separate approval
must be obtained for each establishment desiring to sell watercraft refund motor fuels.
DO NOT COMPLETE—FOR DEPARTMENT USE ONLY
Approved
Disapproved
By
Title
Date
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