Fillable Printable Form 795 - Missouri Motor Fuel Tax License Application
Fillable Printable Form 795 - Missouri Motor Fuel Tax License Application
Form 795 - Missouri Motor Fuel Tax License Application
Missouri Motor Fuel Tax
Application and Instructions
Missouri Department of Revenue
r New Application r Change r Reinstatement
List license number if making a change or requesting reinstatement: ___________________________________________________
Form
795
Missouri Department of Revenue
Missouri Motor Fuel Tax License Application
Business Name and Location
Section 1
Missouri Tax Identification Number IRS 637 Number Federal Identification Number Do you have internet access?
r Yes r No
Business Name E-Mail Address Telephone
(__ __ __)__ __ __–__ __ __ __
DBA Name Internet Site Address (Web Page) Fax
(__ __ __)__ __ __–__ __ __ __
Physical Location of Business City State ZIP Code County
Business Mailing Address City State ZIP Code County
Books and Records Address City State ZIP Code County
Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax information
can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax
information, you must supply us with a power of attorney giving us the authority to release confidential information to them.
Contact Person for Registration Telephone Number E-Mail Address
(__ __ __)__ __ __–__ __ __ __
Contact Person Reporting Telephone Number E-Mail Address
(__ __ __)__ __ __–__ __ __ __
Contact Persons
Section 2
r Supplier or position holder in a Missouri terminal (owns product in the terminal for sale or exchange)
r Export Fuel from Missouri List State(s) and License Number(s) _______________________________________________________
r Participate in Exchanges List Exchange Partners __________________________________________________________________
Effective Date for License (MM/DD/YYYY) __ __/__ __/__ __ __ __ Complete Sections 1 Through 16
Type of Activity (select all that apply)
Section 3
r Permissive Supplier or Position Holder in an Out-Of-State Terminal (Out-Of-State Supplier that elects to have a supplier’s license)
Effective Date for License (MM/DD/YYYY) __ __/__ __/__ __ __ __ Complete Sections 1 Through 13, 15 and 16
r Terminal Operator or Operating a Missouri Terminal (owns, operates or controls a terminal) Type of Terminal r Barge r Pipeline
Do you commingle products with those of any other company? r Yes r No
If Yes, list company name(s) _______________________________________________________________________________________
Effective Date for License (MM/DD/YYYY) __ __/__ __/__ __ __ __ Complete Sections 1 Through 9, 12, 15 and 16
r Distributor (imports, exports or blends motor fuel and may qualify as an eligible purchaser authorized to purchase on a tax deferred basis)
Imports - List name of state(s) and license number(s) _____________________________________________________________________
Exports - List name of state(s) and license number(s) _____________________________________________________________________
Blends - List types of fuels blended ___________________________________________________________________________________
r My company wishes to qualify for “eligible purchaser” status as provided for under Section 142.848, RSMo, to purchase fuel on a tax deferred basis.
Effective Date for License (MM/DD/YYYY) __ __/__ __/__ __ __ __ Complete Sections 1 Through 11 and 14 Through 16
r Transporter (operates a pipeline, barge, railroad or transport truck transporting fuel in Missouri)
Do you transport fuel for hire in Missouri? r Yes r No
Effective Date for License (MM/DD/YYYY) __ __/__ __/__ __ __ __ Complete Sections 1 Through 11, 15 and 16
Type of Product (select all that apply)
Section 4
r Gasoline r Ethanol r Aviation Gasoline r Undyed Kerosene r Undyed Diesel Fuel r Bio-Diesel
r Alcohol r Gasohol r Jet Fuel r Dyed Kerosene r Dyed Diesel Fuel r Bio-Diesel - Dyed
r Compressed Natural Gas (CNG) r Liquefied Natural Gas (LNG) r Propane r Other ______________
Mail to: Taxation Division Phone: (573) 751-2611
P.O. Box 300 Fax: (573) 522-1720
Jefferson City, MO 65105-0300 TTY: (800) 735-2966
E-mail: [email protected]
Visit http://www.dor.mo.gov/business/fuel/
for additional information.
Form 795 (Revised 09-2017)
Supplier or Permissive Supplier _________________________
Distributor __________________________________________
Transporter _________________________________________
Terminal Operator ___________________________________
Eligible Purchaser
r Yes r No
Office Use Only
(License Numbers)
Reset Form
Print Form
Page 2
Terminal Number Where
Product Is Received
How Product
Is Received
Activity Type
Phone Number
Federal I.D.
Number
License
Number
Product
Type
Name of Supplier
or Customers
Type of Ownership
Section 5
Please indicate your ownership type.
r Sole Owner (may include spouse) r Non-Missouri Corporation – Certificate of Authority Number ___________
r Partnership Limited Liability Company:
r Limited Partnership – LP Number ________________________ r Taxed as a Partnership r Taxed as a Sole Owner
r Limited Liability Partnership – LLP Number ________________ r Government r Taxed as a Corporation LLC Number ___________
r Limited Liability Limited Partnership – LLLP Number __________ r Not required to register with Missouri Secretary of State
r Trust r Date Incorporated (MM/DD/YYYY) __ __/__ __/__ __ __ __
r Other ______________________________________________ r State of Incorporation and Date Registered in Missouri
_____________________________________________________ (MM/DD/YYYY) __ __/__ __/__ __ __ __
Previous ownership information (complete only if you purchased an exsisting business).
Section 7
Name of Previous Owner of Business Date Business Closed or Changed Ownership (MM/DD/YYYY)
__ __/__ __/__ __ __ __
Business Name License Number(s)
Ownership Information - Provide information for sole proprietor, all partners, all members of any partnerships or principal officers of any LLC or
corporation (attach a list if necessary).
Section 6
Name (Last, First, Middle Initial) Title
Social Security Number Effective Date (MM/DD/YYYY) Ending Date (MM/DD/YYYY) Birthdate (MM/DD/YYYY)
__ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __
Home Address City State ZIP Code County
Name (Last, First, Middle Initial) Title
Social Security Number Effective Date (MM/DD/YYYY) Ending Date (MM/DD/YYYY) Birthdate (MM/DD/YYYY)
__ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __
Home Address City State ZIP Code County
Name (Last, First, Middle Initial) Title
Social Security Number Effective Date (MM/DD/YYYY) Ending Date (MM/DD/YYYY) Birthdate (MM/DD/YYYY)
__ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __
Home Address City State ZIP Code County
Section 8
Names of any persons associated with this company who presently or previously owned, operated, or managed another motor fuel company
(attach a list if necessary).
Company Name Name (Last, First, Middle Initial)
Title Social Security Number Birthdate (MM/DD/YYYY)
__ __/__ __/__ __ __ __
Home Address City State ZIP Code License Number(s)
Company Name Name (Last, First, Middle Initial)
Title Social Security Number Birthdate (MM/DD/YYYY)
__ __/__ __/__ __ __ __
Home Address City State ZIP Code License Number(s)
Fuel suppliers, customers, or position holders (attach a list if necessary).
Section 9
Suppliers - List to whom you sell fuel Distributors - List your suppliers
Transporters - List those for whom you contract to haul fuel Terminal Operators - List all position holders in your terminal
1. Terminal Street Address Terminal Code City State ZIP Code
T - -
2. Terminal Street Address Terminal Code City State ZIP Code
T - -
3. Terminal Street Address Terminal Code City State ZIP Code
T - -
4. Terminal Street Address Terminal Code City State ZIP Code
T - -
5. Terminal Street Address Terminal Code City State ZIP Code
T - -
6. Terminal Street Address Terminal Code City State ZIP Code
T - -
7. Terminal Street Address Terminal Code City State ZIP Code
T - -
Page 3
Transporter Name
Federal I.D. Number License Number ModePhone Number
List all common carriers you hire to transport fuel
Section 10
Year
State
Registered
Vehicle Identification Number
or Trailer Serial Number
Total Capacity
Gallons
Tank
Wagon
Make
Conveyance method used for transportating fuel
Section 11
If using your own transport trucks, list transportation equipment (attach list if necessary)
If you wish to obtain tank wagon permits for any vehicles listed below, please indicate by placing a check mark in the last column.
r Pipeline r Barge r Ship r Railroad r Truck r Stationary Transfer r Other
Model
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
Terminal Information (attach list if necessary)
Section 12
Terminal Operators list in-state terminals; Suppliers list in-state terminals; Permissive Suppliers list out-of-state terminal information
We elect to treat all removals from all out-of-state terminals with a destination into Missouri as shown on the terminal-issued shipping papers as if
the removals were removed across the rack by the supplier from a terminal in Missouri as provided in Section 142.839, RSMo.
We agree to precollect the Missouri motor fuel tax in accordance with Chapter 142 on all removals from a qualied terminal where we are a position
holder without regard to the license status of the person acquiring the fuel, the point or terms of the sale or the character of delivery.
We further agree to waive any defense that the State of Missouri lacks jurisdiction to require collection on all out-of-state sales by such person as to
which the person had knowledge that the shipments were destined for Missouri and that Missouri imposes the requirements under its general police
powers to regulate the movement of motor fuels.
Notice of Election must be signed by an authorized representative of the company as listed on page 2, Section 6 of the license application.
Signature of Owner, Partner, or Authorized Ofcer Name of Person Signing (Print or Type Name) Date (MM/DD/YYYY)
__ __/__ __/__ __ __ __
Notice of Election (Suppliers and Permissive Suppliers Only)
Section 13
This notice of election provides for the precollection of the Missouri motor fuel tax on all removals from all out-of-state terminals listed above
where suppliers or permissive suppliers are position holders.
Page 4
Product Type
Total Tank Capacity
County
City or Town
Missouri Storage Tank Information (attach list if necessary)
Section 14
Product Types r Gasoline r Aviation Gasoline r Undyed Kerosene r Undyed Diesel Fuel r LNG
r Alcohol r Gasohol r Jet Fuel r Dyed Kerosene r Dyed Diesel Fuel r Other _________________
List storage tank information by product type, city or town location, total tank capacity per city or town and the county.
Bond Information (estimated number of gallons of fuel handled per month per activity type)
Section 15
Signature
Under the penalty of perjury, I hereby certify that information contained herein is true, complete and correct. If indicated in Section 3, I hereby elect to
obtain “eligible purchaser” status.
Section 16
Company Name
Signature of Owner, Partner or Authorized Officer Print Name of Person Signing the Application Date (MM/DD/YYYY)
__ __/__ __/__ __ __ __
Gas ______________________ Gas ______________________ Gas _______________________ Gas ________________________
Gasohol ___________________ Gasohol ___________________ Gasohol ___________________ Gasohol _____________________
Diesel _____________________ Diesel _____________________ Diesel _____________________ Diesel ______________________
Kerosene __________________ Kerosene __________________ Kerosene __________________ Kerosene ____________________
Dyed Diesel ________________ Dyed Diesel ________________ Dyed Diesel ________________ Dyed Diesel __________________
Dyed Kerosene _____________ Dyed Kerosene _____________ Dyed Kerosene ______________ Dyed Kerosene _______________
AV Gas ___________________ AV Gas ____________________ AV Gas ____________________ AV Gas _____________________
Jet Fuel ___________________ Jet Fuel ___________________ Jet Fuel ___________________ Jet Fuel _____________________
Alcohol ____________________ Alcohol ____________________ Alcohol ____________________ Alcohol ______________________
CNG______________________ CNG ______________________ CNG ______________________ CNG _______________________
LNG ______________________ LNG ______________________ LNG ______________________ LNG ________________________
Propane ___________________ Propane ___________________ Propane ___________________ Propane _____________________
r Surety Bond r Surety Bond r Surety Bond r Surety Bond
r Certificate of Deposit r Certificate of Deposit r Certificate of Deposit r Certificate of Deposit
r Letter of Credit r Letter of Credit r Letter of Credit r Letter of Credit
r Cash Bond r Cash Bond r Cash Bond r Cash Bond
r Proof of Financial r Pool Bond
Responsibility (See Instructions)
(See Instructions)
Distributor
Supplier or Permissive
Supplier
Terminal Operator
Transporter
Distributor
Supplier or Permissive
Supplier
Terminal Operator
Transporter
List gallons handled by product types as grouped below
Bond Type
Form 795, Missouri Motor Fuel Tax License Application
Type of Application
Place a check mark in the appropriate box. If you already have a Missouri fuel tax number and wish to make changes or
have your license reinstated, please provide license number in the space provided.
Missouri Tax I.D. Number
If you have an 8-digit Missouri Tax I.D. Number, enter that number in the space provided, otherwise leave blank.
IRS 637 Number (Number issued by IRS for various excise tax activities)
If you have an IRS 637 Number, enter that number in the space provided. If you do not have an IRS 637 number, leave blank.
Federal Employer I.D Number
Enter the Federal Employer Identification Number issued to your company by the Federal Government. If you do not have
a Federal Employer I.D. Number, leave blank.
Section 1 - Business Name and Location
Enter your business name, DBA, physical location of business, mailing address, address where books and records are
kept, county, fax number, telephone number, if you have Internet access and/or a web page and your email address.
Section 2 - Contact Persons
Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department
of Revenue are confidential. The tax information can only be given to the owner, partner, member, or officer who is
listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax information, you
must supply us with a power of attorney giving us the authority to release confidential information to them.
Section 3 - Type of Activity
For each activity you plan to conduct in Missouri, place a check mark in the appropriate box and provide the requested
information.
Please indicate the effective date for your license for each activity type you are applying for. This date should not be
before the issue date of the bond you will be posting.
Section 4 - Product Types
For each type of motor fuel you plan to handle, place a check mark in the appropriate box. If a product is not listed, check
the box marked “other” and list the name of the product(s).
Section 5 - Type of Ownership
Place a check mark in the box that describes the ownership structure of your business and provide the required information.
If your company is not in compliance with the Missouri Secretary of State’s office, you will need to contact them in order
to determine if you need to be registered. You may reach them by telephone at (573) 751-3827 or visit their website at
http://www.sos.mo.gov/. If your company does not meet their requirements to register, please remit a letter along with
your application stating the reason for exemption.
Section 6 - Ownership Information
Provide the requested information for the owners, partners, members or officers of the business.
Section 7 - Previous Ownership Information
Provide the requested information only if you purchased an existing business.
Section 8 - Previous Motor Fuel Experience
Provide the requested information for any owner, officer, or employee who presently or previously, owned, operated or
managed another motor fuel company.
Section 9 - Fuel Suppliers/Customers
Complete this section as follows:
Suppliers - List to whom you sell fuel, phone number, Federal I.D. Number, License Number, product type, Terminal
Number where product is received, how received. (Example: ABC Refinery, 555-555-5555, 44-4444444, S0000, gas,
T-43-MO-3700, Pipeline)
Distributors - List the suppliers from whom you purchase fuel, telephone number, Federal I.D. Number,
License Number, Product Type, Terminal number where product is, how received.
(Example: ABC Oil Co, 555-555-5555, 44-4444444, S0000, diesel, T-43-MO-3700, Truck)
Transporters - List the companies for whom you haul fuel, telephone number, Federal ID Number, License
Number, Product Type, Terminal number where product is received, transport method. (Example: ABC Oil Co,
555-555-5555, 44-4444444, D0000, gas, T-43-MO-3700, Truck)
Terminal Operators - List the companies that are position holders in your terminal, telephone number, Federal I.D.
Number, License Number, Product Type, Terminal number where product is received, how product is received.
(Example: ABC Oil Co, 555-555-5555, 44-4444444, S0000, gas, 43-MO-3700, Pipeline or Barge)
Section 10 - Common Carrier Information
Provide the requested information for the companies that you hire to transport your fuel.
Section 11 - Conveyance Method
If you are a transporter, supplier or distributor transporting your own fuel or hauling for hire, select the appropriate box
for transport method. If you are using your own transport trucks, please provide the requested information. If you have a
tank wagon operation and wish to obtain tank wagon permits for your vehicles, please provide the requested information
and place a check mark in the “Tank Wagon” column. (Obtaining tank wagon permits allows you to import fuel that the
Missouri fuel tax and fees have not been precollected on, without calling for an import verification number and without
having to pay the fuel taxes and fees within three (3) days.)
Section 12 - Terminal Information
Suppliers - Provide the requested information for Missouri terminals in which you are a position holder and any out-of-
state terminal in which you are a position holder and will collect the Missouri tax on all removals destined to Missouri.
Permissive Suppliers - Provide the requested information for any out-of-state terminal in which you are a position holder
and agree to precollect the Missouri tax on all removals destined for Missouri.
Terminal Operators - Provide the requested information for the Missouri terminal you operate.
Section 13 - Notice of Election
Indicate if you are a position holder or supplier in an out-of-state terminal and agree to collect Missouri taxes and fees on
all removals destined for Missouri without regard to the license status of the person acquiring the motor fuel. If you make
this election, you must collect Missouri taxes and fees on all removals destined for Missouri from all terminals in which you
are a position holder.
Section 14 - Missouri Storage Tank Information
Please furnish the requested information for all storage tanks you have in Missouri. It is not necessary to list individual
tanks. Show the total storage capacity for each product type for each location.
Section 15 - Bond Information
Provide the estimated number of gallons you will handle for each activity and product type as listed.
Place a check mark in the box for each activity type you are applying for and the type of bond you are submitting. Bond
amount is based on 3 times the monthly liability based on the number of all gallons handled.
All persons applying for more than one activity type must submit a separate bond for each activity. The only exception is for
suppliers and permissive suppliers. Only suppliers and permissive supplier may provide “proof of financial responsibility”
in lieu of filing a bond.
Proof of financial responsibility may be provided for the entire bond, 1/2 of the required bond or 1/4 of the required bond
(submit annual financial report)
1. $5,000,000 net worth in lieu of total bond amount required
2. $2,500,000 net worth in lieu of 1/2 of bond amount required Net worth is calculated on a company,
not individual state basis
3. $1,250,000 net worth in lieu of 1/4 of bond amount required
Transporters may meet the initial bonding requirement by posting a $1,500 bond. The director may request an increase
up to the maximum amount.
Distributors that were licensed prior to January 1, 1999, and were not required to provide a bond under the previous law
and distributors, licensed after January 1, 1999, who have 3 consecutive years of satisfactory tax compliance, may elect
to participate in the pool bond. The current pool bond rate is .0024 per gallon of motor fuel, .0013 per gallon of aviation
fuel and .0007 per gallon of CNG, LNG, or propane based on all gallons purchased in Missouri or on all gallons imported
into Missouri.
Section 16 - Signature
Provide the requested information. The person signing the application must be listed in Section 6 or there must be a
Power of Attorney attached for the person signing. In addition the person whose signature appears in this section is
attesting that “Eligible Purchaser Status” was requested in Section 3.
