Mfa 1 Form – Fill Out and Use This PDF

Ne w Je rse y Divisio n o f Ta xa tio n

PO BO X 189

TRE NTO N, NJ 08695-0189

C o m b ine d Mo to r Fue ls

Fo rm MFA - 1

Lic e nse A p p lic a tio n

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.

Section 3 – Information on Prior License Holder (Retailer’s Only)

Complete for initial applications only

Section 4 – Type of Ownership

Section 5 – Owner Information

Provide information for sole proprietor, all partners, or principal officers of corporations or limited liability corporations (attach rider if necessary).

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 N.J.S.A. §54:39-101 et. seq. (attach rider if necessary).

Section 7 – Types of Products Handled

Check each type of product you will be dealing with in New Jersey.

Other – List each:

______________________________________________________________________________________________________________

1. You engage in the business of selling or dispensing motor fuel to the consumers in this state.

2. You operate a blocked pump for clear kerosene.

3. You sell Aviation Fuels to theconsumers.

4. You dispense LPG into on-road vehicles.

6.If yes, please submit a description.

7.If no, is your station pre-wired for a generator?

For each fuel transportation vehicle or vessel, give the following information. (Attach rider if you are licensing more than 20 vehicles or vessels).

Total application fee due for this application: $

Section 9 – Consumer Registration

Only consumers may complete this section. If you sell fuel, then you are not a consumer and you must apply for one of the licenses in Section 8.

Section 10 – Fuel Customers / Suppliers / Position Holders

Supplier of Motor Fuels applicants: list your customers. Distributor of Motor Fuels applicants: list your suppliers.

Terminal Operator applicants: list the position holders in your terminal(s). Retailers of Motor Fuels applicants: list your suppliers.

Section 11 – Transporters Hired

List common carriers you will use to transport fuel.

Section 12 – Terminals

Refer to instructions to determine which terminals must be listed (attach rider if necessary).

Section 13 – New Jersey Storage Tank Information

List all storage tank information, both above and below ground, by product type (attach rider if necessary).

Section 14 – Bond Information

Complete the parts applicable to the license you are requesting.

Section 15 – Optional Election to be an Elective Supplier or Permissive Supplier

THIS NOTICE OF ELECTION PROVIDES FOR THE PRECOLLECTION OF THE NEW JERSEY MOTOR FUEL TAX ON ALL REMOVALS FROM ALL OUT-OF-STATE TERMINALS LISTED IN SECTION 12 WHERE SUPPLIERS OR PERMISSIVE SUPPLIERS ARE POSITION HOLDERS.

We elect to treat all removals from all out-of-state terminals with a destination into New Jersey as shown on the terminal-issued shipping papers as if the removals were removed across the rack by the supplier from a terminal in New Jersey as provided in Section 54:39-118.

We agree to pre-collect the New Jersey Motor Fuels Tax in accordance with Chapter P.L 2010. C22 on all removals from a qualified terminal in which we are a position holder, without regard to the license status of the person acquiring the fuel, the point of terms of the sale or the character of delivery.

We further agree to waive any defense that the State of New Jersey 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 New Jersey and that New Jersey 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 in Section 5 of this application. My signature affirms all of the above.

Section 16 – Optional Election to be a Qualified Distributor

Pursuant to Section 54:39-121, Qualified Distributors may delay remittance of the tax pre-collected by their Suppliers and Permissive Suppliers until up to the 20th day of the month following the removal of taxable products from a terminal by a fuel transportation vehicle. Payments made to Suppliers and Permissive Suppliers MUST be made by electronic funds transfer (EFT).

We acknowledge our Suppliers’ obligations to pre-collect tax due on motor fuels from us, hold it in trust for New Jersey, and remit the pre-collected tax no later than the 22nd of the month following the taxable event.

We affirm that:

1.Our company was a licensee in good standing with the State of New Jersey under R.S. 54:39-1 et seq. Our filings and payments were made accurately and timely.

—OR —

2.Our company meets the financial responsibility or bonding requirements set forth by the Motor Fuels Tax Act of 2010.

We agree that in order to enable our Suppliers to meet their obligations to the State of New Jersey, we MUST remit the amount of tax due to our Suppliers by EFT no later than the 20th day of the month following the taxable event.

Based on the above acknowledgment, affirmation, and agreement, we request that the State of New Jersey recognize us as a Qualified Distributor pursuant to R.S. 54:39-101 et seq. We are qualified to delay remittance to our Suppliers of tax due until the 20th day of the month following the taxable event. We recognize that our company, and not our Suppliers, will be liable for penalties and interest in the event that we are late in making remittance to our Suppliers. We further recognize that a late remittance to our Suppliers will revoke our status as a Qualified Distributor.

QUALIFIED DISTRIBUTOR APPLICATION must be signed by an authorized representative of the company as listed in Section 5 of this application. My signature affirms all of the above.

All Applicants must sign the following section.

Section 17 – Authorizing Signature

Under penalty of perjury, my signature affirms all of the following:

The information provided in this application, to include all attachments, is accurate and complete to the best of my knowledge.

The applicant agrees to provide accurate and timely reports and to make timelypayments.

Inaccurate or incomplete information in any section is cause for denial of the requests made in Section 15 or 16, and/or the denial of the entire application.