Form MFA-1 "Combined Motor Fuels License Application" - New Jersey

What Is Form MFA-1?

This is a legal form that was released by the New Jersey Department of the Treasury - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2013;
  • The latest edition provided by the New Jersey Department of the Treasury;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MFA-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of the Treasury.

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Download Form MFA-1 "Combined Motor Fuels License Application" - New Jersey

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Division use only – DLN Stamp
Division use only – Date Stamp
Send to:
Rev 12-2013
New Jersey Division of Taxation
PO Box 189
Trenton, NJ 08695-0189
Combined Motor Fuels
Form MFA-1
License Application
Initial Application
Change Application
Renewal Application
Section 1 – Business Information
Federal ID Number
IRS 637 Number
New Jersey Tax ID Number
Does your company have
Yes
internet access?
No
Business Name
Webpage Address
Trade Name
Phone Number
Fax Number
Physical Address
Mailing Address
Books and Records Address
Hours of Operation
Mon.
--
Tues.
--
Wed.
--
Thur.
--
Fri.
--
Sat.
--
Sun.
--
Section 2 – Contact Information
If you wish to give an attorney, or accountant access to your tax information, you must supply us with an Appointment of Taxpayer
Representative Form (Form M-5008-R) giving us the authority to release confidential information to them.
Contact for Registration
Title
Telephone No
Email Address
Contact for Reporting
Title
Telephone No
Email Address
Site Manager
Title
Telephone No
Email Address
Individual Completing this Form
Title
Telephone No
Email Address
Section 3 – Prior Owner Information
Complete if you are purchasing an existing business.
Former Business Name
Former License Number
Former Phone Number
Former Business Address
City, State, Zip
Date Ownership Transferred
Former Business Mailing Address
City, State, Zip
Date Former Business Ended
Section 4 – Type of Ownership
Sole Proprietorship (may include spouse)
Partnership
Limited Partnership
Limited Liability Partnership
Government Entity
Trust
New Jersey Corporation
Out-of-State Corporation – State: _______
Other (specify)
Date of Incorporation: __________
Date Registered in New Jersey:
_______
___________________________
Section 5 – Owner Information
Provide information for sole proprietor, all partners, or principal officers of corporations or limited liability corporations
(attach rider if necessary).
Name (Last, First, M)
Title
Social Security Number
Home Address
Home Phone Number
Cell Phone Number
Name (Last, First, M)
Title
Social Security Number
Home Address
Home Phone Number
Cell Phone Number
Name (Last, First, M)
Title
Social Security Number
Home Address
Home Phone Number
Cell Phone Number
Name (Last, First, M)
Title
Social Security Number
Home Address
Home Phone Number
Cell Phone Number
Section 6 – Relationships with Other Organizations
Information regarding persons affiliated with this business who either are also affiliated or have been affiliated with another
business that requires licensing under NJSA §54:39-101 et. seq. (attach rider if necessary).
Individual’s Name
Title with Applicant
Date Joining Applicant
Social Security Number
Individual’s Home Address
City, State, Zip
Name of Business with which Affiliation Exists
Affiliated Business FID
Title
Effective Date of Title
Address of Business with which Affiliation Exists
City, State, Zip
Individual’s Name
Title with Applicant
Date Joining Applicant
Social Security Number
Individual’s Home Address
City, State Zip
Name of Business with which Affiliation Exists
Affiliated Business FID
Title
Effective Date of Title
Address of Business with which Affiliation Exists
City, State Zip
Section 7 – Types of Products Handled
Check each type of product with which you will be dealing in New Jersey.
Gasoline
LPG
Dyed Kerosene
Undyed Kerosene
Gasohol
Undyed Diesel
Undyed Biodiesel
Aviation Fuel
Fuel Grade Alcohol
Dyed Diesel
Dyed Biodiesel
Other – List each other
product:
Section 8 – Business Activity; License Requested
Check all that apply.
Supplier of Motor Fuels
An Application Fee of $450 is due for a 3-year license.
1.
You are registered or required to be registered pursuant to Section 4101 of the Federal Internal Revenue Code of 1986 and one or more of A through E.
A.
You are a Position Holder in a terminal in New Jersey (List each Terminal and its location).
o
B
You export fuel from this State (List the states to which you export and your License N
in each state).
o
C.
You Import as a Position Holder in another state (List the states from which you import and your License N
in each state).
o
D.
You Import from another Position Holder (List the Position Holders, the Position Holder’s License N
, and the state).
o
E.
You acquire Motor Fuel in this State by two-party exchanges (List exchange partners and their License N
).
2.
You produce Fuel Grade Alcohols in New Jersey or for import into New Jersey.
Permissive Supplier of Motor Fuels
An Application Fee of $450 is due for a 3-year license.
You are an out-of -State Supplier who is not required to be licensed as a Supplier in this State, but you elect to be licensed anyway.
An Application Fee of $450 is due for a 3-year license for each
Terminal Operator
Terminal Operated.
1.
You own one or more Terminals in New Jersey (List each Terminal, state whether it is a barge, pipeline, or fixed location, and its location).
2.
You control one or more Terminals in New Jersey (List each Terminal, state whether it is a barge, pipeline, or fixed location, and its location).
3.
You commingle products with those of another company (List each company and the products commingled).
Distributor of Motor Fuels
An Application Fee of $450 is due for a 3-year license.
1.
You acquire Fuel from a Supplier, Permissive Supplier, or another Distributor for subsequent resale.
o
2.
You import Fuel from another state (List the states, Suppliers, each Supplier’s License N
and the products imported).
o
3.
You export Fuel to another state (List the states, customers, each customer’s License N
, and the products exported).
4.
You blend Fuels (List the types of fuels you blend and the blendstocks used).
5.
You sell Aviation Fuel.
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