CRF-007 (Rev. 8/13) STATE OF GEORGIA DEPARTMENT OF REVENUE INSTRUCTION FOR COMPLETION OF THE MOTOR FUEL DISTRIBUTOR APPLICATION (CRF-007) TYPE OR PRINT IN INK ­ DO NOT USE PENCIL Use this form to apply for a Motor Fuel Distributor License. Any person who produces, refines, prepares, distills, manufactures, blends, or compounds motor fuels in this state; imports and/or exports motor fuels for sale; or sells motor fuel to the United States Government, must obtain a distributor license. In addition, any person who consumes or uses motor fuels or other than gasoline for both highway and non-highway use or sells this fuel to consumers who have both highway and non-highway use may obtain a distributor license. Any license issued under Ga. Code 48-9-1 shall indicate the type of motor fuel distributor is licensed to distribute. A. INSTRUCTIONS FOR PAYMENT: A filing fee of $10.00 and completed application for each license type must be attached. Payment is made payable to GEORGIA DEPARTMENT OF REVENUE. Georgia law stipulates that taxes and fees shall be paid in lawful money of the U.S. and be free of any expense to Georgia. A bond must be posted for an amount sufficient to cover three times your monthly tax liability. Your monthly tax liability amount is the number of taxable gallons times 7 ½ cents plus the applicable state pre-paid tax rate during the period in which you are applying for your license. PLEASE NOTE THAT YOUR ACTUAL TAX LIABILTY WILL BE REVIEWED PERIODICALLY WHICH MAY REQUIRE YOUR BOND TO BE INCREASED. B. INSTRUCTIONS FOR COMPLETING: Line 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 Line 8 Line 9 Line 10 Line 11 Line 12 Line 13 Line 14 Line 15 Enter your Georgia State Taxpayer Identifier. (If you do not have one, please complete form CRF-002) Enter your Georgia Sales Tax number and FEI number (Federal ID). * License will not be issued without these numbers If registered with the Secretary of State, enter the name under which your business is legally registered. If you business is not registered, then enter the name under which you plan to operate. Enter the Physical location of your business. * PO BOX IS NOT AN ACCEPTABLE LOCATION ADDRESS Check the type Distributor License for which you are applying. * EACH TYPE MUST HAVE A SEPARATE APPLICATION Enter the date (MMDDYY) you will begin distributing motor fuels in Georgia. * DATE SHALL NOT EXCEED MORE THAN 30 DAYS BEFORE SUBMISSION OF YOUR APPLICATION Check the type business you operate. Enter your estimated monthly sales (in gallons) to retail (service stations) and wholesale (other distributors) customers; and whether the sales will be taxable and/or non-taxable by fuel type. Check "YES" or "NO" in the spaces provided for Fuel Oils, LP gas, and Special Fuels. Enter your estimated monthly volume of imports and/or exports (in gallons) for the Fuel Type listed. *EXPORTS MUST BE 10% OF YOUR MONTHLY VOLUME Enter your vendor account number if you sell motor fuels to the U.S. Government. Check "YES" or "NO" in the space provided. * EXPORTER ONLY Enter the state in which you take possession of the fuel. Enter your estimated monthly usage in gallons, taxable and non-taxable for the fuel types listed. Enter your estimated monthly usage in gallons of Aviation Gasoline. C. INSTRUCTIONS FOR SIGNING: This application must be signed by the owner, a partner, or an authorized officer of the corporation. D. INSTRUCTIONS FOR AFFIDAVIT AND REQUIRED DOCUMENTATION: The taxpayer must complete Page 3 of Form CRF-007. A notary seal is required in order to process registration application. One secure and verifiable document must be submitted and attached to the application as required by O.C.G.A. 50-36-1(e)(1). Please scan and upload the front and back of secure and verifiable document. Keep a copy for your records. Failure to submit required affidavit and additional documentation will result in denial of registration. E. INSTRUCTIO NS FOR MAILING AND REQUESTI NG ADDITIONAL INFORMATION: The taxpayer should retain a copy of this application for their file and for inspection by the Revenue Commissioner or his agent. Mail the original to the address shown below. If you have any questions or need assistance in completing the application, call 1 (877) 423-6711, e-mail TSD-motor-fuel-lic@dor.ga.gov or write to the following address: Georgia Department of Revenue Taxpayer Services Division PO Box 49512 Atlanta, GA 30359-1512 THE PROCESSING OF THIS APPLICATION MAY BE DELAYED UNLESS IT IS PROPERLY SIGNED, PLEASE USE THE CHECK LIST BELOW BEFORE MAILING APPLICATION(S) TO INSURE THAT THE APPLICATION(S) IS COMPLETE. [ ] CRF-002 STATE REGISTRATION APPLICATION SIGNATURE REQUIRED ON BOND [ ] CRF-007 MOTOR FUEL DISTRIBUTOR APPLICATION [ ] $10.00 PROCESSING FEE American LegalNet, Inc. www.FormsWorkFlow.com [ ] FS-MFD-26 MOTOR FUEL DISTRIBUTOR'S BOND (IF APPLICABLE) CRF-007 (Rev. 8/13) GEORGIA DEPARTMENT OF REVENUE TAXPAYER SERVICES DIVISION PO BOX 49512 ATLANTA, GA 30359-1512 1-877-423-6711 TSD-motor-fuel-lic@dor.ga.gov MOTOR FUEL DISTRIBUTOR APPLICATION STATE TAXPAYER IDENTIFIER LEGAL BUSINESS NAME LOCATION ADDRESS GEORGIA SALES TAX NUMBER (READ INSTRUCTIONS BEFORE COMPLETING) (Form CRF-002 must be completed before license can be issued) 2 TELEPHONE NUMBER CITY OFFICE USE ONLY TOTAL AMT RECEIVED $ DISTRIBUTOR LICENSE NO. FEIN (FEDERAL IDENTIFIER NUMBER) E-MAIL ADDRESS STATE ZIP CODE 1 3 4 5 6 7 8 FOR WHICH TYPE OF DISTRIBUTOR LICENSE ARE YOU APPYLING FOR? [ ] MOTOR FUELS, INCLUDING GASOLINE. *Must be Importing and Exporting [ ] MOTOR FUELS, EXCLUDING GASOLINE. *Please specify JET FUEL. [ ] SPECIAL FUELS WHEN DID OR WILL YOU START DISTRIBUTING OR USING MOTOR FUELS? TYPE OF BUSINESS [ ] RESELLER [ [ ] LP (LIQUID PROPANE) [ ] AVIATION GASOLINE ] DUAL USER (Does not include Fuel Oils) WHOLESALE Non-Taxable FUEL TYPE GASOLINE FUEL OILS JET FUEL LP GAS SPECIAL FUELS GEORGIA ANTICIPATED MONTHLY SALES IN GALLONS RETAIL Taxable Non-Taxable Taxable 9 10 AVIATION GASOLINE * Not Including Jet Fuels * DO YOU SELL TO CONSUMERS THAT HAVE TAXABLE USE OF THESE FUELS? [ ] FUEL OILS [ [ ] LP GAS ] YES [ [ ] SPECIAL FUELS ] NO ANTICIPATED MONTHLY IMPORTS AND EXPORTS IN GALLONS FUEL TYPE GASOLINE FUEL OILS JET FUEL LP GAS SPECIAL FUELS AVIATION GASOLINE * Not Including Jet Fuels * FOR SALES TO US GOVERNMENT, LIST VENDOR ACCOUNT NUMBER (If applicable) WILL YOU BE EXPORTING ALL YOUR GASOLINE PURCHASES? [ ] YES [ ] NO IMPORTS EXPORTS 11 12 14 ANTICIPATED MONTHLY USE IN GALLONS (Highway and