Form 72A135 "Application for Kentucky Motor Fuels Tax Refund Permit" - Kentucky

What Is Form 72A135?

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

Form Details:

  • Released on April 1, 2009;
  • The latest edition provided by the Kentucky Department of Revenue;
  • 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 printable version of Form 72A135 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Revenue.

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Download Form 72A135 "Application for Kentucky Motor Fuels Tax Refund Permit" - Kentucky

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72A135 (4-09)
DEPARTMENT USE ONLY
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
__ __ __ __ __ __ __ __ __ __ __ __ / __ __ __ __ __ __
PERMIT NUMBER
EF DT
APPLICATION FOR
KENTUCKY MOTOR FUELS TAX REFUND PERMIT
(KRS 138.344 through 138.355)
Please type or print clearly. ALL QUESTIONS MUST BE ANSWERED.
New Application
Duplicate
Change If duplicate or change, Current Permit Number ___________________________
Applicant’s
Full Name ________________________________________________ Social Security Number __________________________________
Driver’s License Number _________________________________
Business Name
(if applicable) ________________________________________ FEIN (if business) __________________________________
Mailing Address ________________________________________________________________________________________
Street or P.O. Box
City
County
State
ZIP Code
Telephone (daytime) (
)
E-mail Address
1. Type fuel(s) for which refund permit is requested:
Agricultural Gasoline
Agricultural Special Fuels
Other Nonhighway Special Fuels
2. Description of your business or other activity for which refund fuel will be used.
Agricultural
Mining
Manufacturing
Commercial Heating
Other
Brief Description: __________________________________________________________________________________________
If applying for an agricultural permit, indicate the total number of acres owned, leased or rented for agricultural purposes.
____________________________________________________________________________________________________________
3. a. How many licensed motor vehicles do you own or operate which use gasoline? _________________________________________
b. How many licensed motor vehicles do you own or operate which use diesel fuel? _______________________________________
c. If licensed motor vehicles were indicated in line(s) 3a and/or 3b, where is fuel purchased for such licensed motor vehicles?
____________________________________________________________________________________________________________
4. a. Do you also maintain a storage tank for motor fuels to be used in licensed motor vehicles?
Yes
No
b. If yes, which type of fuel?
Gasoline
Special Fuels
Both
(NOTE: Criminal penalty for use of refund fuel in licensed vehicles.)
5. Provide a detailed list of all unlicensed vehicles and equipment in which refund motor fuel(s) will be used.
Attach a separate sheet if necessary.
a. Gasoline __________________________________________________________________________________________________
b. Special Fuels (diesel) ________________________________________________________________________________________
(continued on reverse)
72A135 (4-09)
DEPARTMENT USE ONLY
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
__ __ __ __ __ __ __ __ __ __ __ __ / __ __ __ __ __ __
PERMIT NUMBER
EF DT
APPLICATION FOR
KENTUCKY MOTOR FUELS TAX REFUND PERMIT
(KRS 138.344 through 138.355)
Please type or print clearly. ALL QUESTIONS MUST BE ANSWERED.
New Application
Duplicate
Change If duplicate or change, Current Permit Number ___________________________
Applicant’s
Full Name ________________________________________________ Social Security Number __________________________________
Driver’s License Number _________________________________
Business Name
(if applicable) ________________________________________ FEIN (if business) __________________________________
Mailing Address ________________________________________________________________________________________
Street or P.O. Box
City
County
State
ZIP Code
Telephone (daytime) (
)
E-mail Address
1. Type fuel(s) for which refund permit is requested:
Agricultural Gasoline
Agricultural Special Fuels
Other Nonhighway Special Fuels
2. Description of your business or other activity for which refund fuel will be used.
Agricultural
Mining
Manufacturing
Commercial Heating
Other
Brief Description: __________________________________________________________________________________________
If applying for an agricultural permit, indicate the total number of acres owned, leased or rented for agricultural purposes.
____________________________________________________________________________________________________________
3. a. How many licensed motor vehicles do you own or operate which use gasoline? _________________________________________
b. How many licensed motor vehicles do you own or operate which use diesel fuel? _______________________________________
c. If licensed motor vehicles were indicated in line(s) 3a and/or 3b, where is fuel purchased for such licensed motor vehicles?
____________________________________________________________________________________________________________
4. a. Do you also maintain a storage tank for motor fuels to be used in licensed motor vehicles?
Yes
No
b. If yes, which type of fuel?
Gasoline
Special Fuels
Both
(NOTE: Criminal penalty for use of refund fuel in licensed vehicles.)
5. Provide a detailed list of all unlicensed vehicles and equipment in which refund motor fuel(s) will be used.
Attach a separate sheet if necessary.
a. Gasoline __________________________________________________________________________________________________
b. Special Fuels (diesel) ________________________________________________________________________________________
(continued on reverse)
6. Estimate the number of refund gallons you will use each year.
Agricultural Gasoline ______________ gallons
Special Fuels (diesel) ________________ gallons
7. List below each storage tank (portable or stationary) and its location you maintain for special fuels or gasoline to be used in all vehicles
or equipment.
Type Fuel
Tank Location
Highway Use
Tank Size
(gasoline, special fuels)
(street or road, city, county, state)
or Nonhighway Use
(in gallons)
8. Are all of the refund storage tanks clearly marked “Refund Motor Fuel” or “Off Road Fuel” as required by law?
Yes
No
NOTE: Portable tanks must also be clearly marked.
9. List the name and address of the licensed distributor (wholesale supplier) who is or will be delivering your refund motor fuel.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
10. List below any Kentucky tax account numbers you are assigned for the following type taxes:
Corporation Income Tax ________________________________________
Withholding Tax ______________________________
Sales and Use Tax _____________________________________________
Unemployment Insurance _______________________
Coal Severance Tax ____________________________________________
Kentucky Highway Users (KYU) _________________
11. a. Did you file a Kentucky income tax return for the immediately preceding calendar or fiscal year?
Yes
No
b. If the answer to line 11a is no, explain __________________________________________________________________________
____________________________________________________________________________________________________________
c. If the answer to line 11a is yes, was the return filed under the same name and Social Security (or federal employer identification)
number listed on the reverse side of this application?
Yes
No
d. If the answer to line 11c is no, explain and provide the name and number under which the return was filed. ___________________
____________________________________________________________________________________________________________
(NOTE: Information on lines 11a through 11d will be compared to income tax records maintained by the Department of Revenue.)
I hereby certify that the information contained herein is true and correct to the best of my knowledge and belief and that the Department of
Revenue will be notified within 10 days of any and all changes to the information provided herein. I understand that failure to notify the
department of such changes may result in cancellation of the permit for which this application is filed. I further acknowledge my understanding
that the submission of any false information on this application or any highway use of refund fuel will subject me to civil and criminal penalties
as provided by law.
___________________________________________
_____________________________________
______________________
Applicant’s Name (Print)
Applicant’s Signature
Date of Application
Mail completed application to Kentucky Department of Revenue, Motor Fuels Tax Compliance Section, Station 63, P.O. Box 1303,
Frankfort, Kentucky 40602-1303, phone (502) 564-3853, fax (502) 564-2906.
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