Tp650 Form – Fill Out and Use This PDF

Read Form TP‑650‑I, INSTRUCTIONS FOR FORM TP‑650, carefully before completing this form. Attach additional sheets as necessary to fully answer all questions.

Print or type. All applicants must complete lines 1 through 14.

9Do you have an IRS Letter of Registration as a result of filing a federal Form 637, Application for Registration (For Certain Excise Tax Activities)?

Mark an X in the box(es) for the license/registration for which you are applying and complete the lines indicated (see instructions):

Page 2 of 4 TP-650 (1/21)

12a List owner(s), officers, directors, partners, and responsible employees (see instructions). Attach additional sheets if necessary.

13During the last five years, has the applicant or any person listed in line 12a:

•owned or controlled, directly or indirectly, more than 10% (25% or more if there are four or fewer shareholders) of the voting stock of a business other than the applicant, or

•been an employee of a business (other than the applicant) who was under a duty to file a return or pay taxes under Articles 12-A or 13-A on behalf of such business, or

•been an officer, director, or partner of a business other than the applicant?

14In the past five years, was any person listed in line 12a convicted of any crime, or was any person listed in line 12a associated with a business (as described in line 13) at the time the business was convicted of any crime (see instructions)?

Lines 15 and 16 should be completed by a distributor of diesel motor fuel, retailer of non‑highway diesel motor fuel only, distributor of kero‑jet fuel only, residual petroleum product business, retail seller of aviation gasoline, distributor of motor fuel, and MCTD motor fuel wholesaler.

15Depending on the type of registration for which you are applying, enter the number of gallons of fuel sold or used in each of the last three years

(see instructions).

19Only importing/exporting transporters should complete line 19.

a. Identify your method(s) of transporting motor fuel (truck, tractor‑trailer, barge, tanker, pipeline, railroad, etc.)

d.List all terminals/storage facilities located in NYS where you load/unload motor fuel: Location of terminal/facility

20Only terminal operators should complete line 20 (attach additional sheets if necessary).

a. List all terminals/storage facilities located in NYS where you will store motor fuel or diesel motor fuel.

b. For all leased terminals/storage facilities listed in line 20a, complete the following:

d. List principal suppliers of each terminal/storage facility:

e. List principal transporters from each terminal:

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21Only distributors of kero-jet fuel only and retail sellers of aviation gasoline should complete line 21 (attach additional sheets if necessary). a. List all places located within NYS where you sell kero‑jet fuel or aviation gasoline:

d. If you are registering as a retail seller of aviation gasoline, do you sell any motor fuel (other than aviation gasoline at retail) at any location within

I certify that all information provided is true and complete, and that this application has been completed with the knowledge that making a willfully false written statement is a felony under Tax Law § 1812(c)(1) and a misdemeanor under Tax Law §§ 1812(c)(2), 1812-f(c)(1), and 1812-f(c)(2) and Penal Law § 210.45 punishable by fines and penalties therein. I further declare that this application has been completed with the knowledge that making a

false statement herein may result in the cancellation, suspension, or revocation of any license or registration issued by the Tax Department pursuant to the tax articles to which this form applies. I also understand that the Tax Department is authorized to investigate the validity of the accuracy of any information entered on this application.

Additional attachments required

If you are applying for a license/registration as a distributor or motor fuel, liquefied petroleum gas fuel permittee, distributor of diesel motor fuel, retailer of

non‑highway diesel motor fuel only, distributor of kero‑jet fuel only, residual petroleum product business, or retail seller of aviation gasoline, you must submit:

•a current financial statement (to register as a distributor of motor fuel, your current financial statement must be a certified, unqualified statement); and

•a letter from each supplier that includes the following information:

–the quantity and type of product that they agree to supply to you each month;

–payment and/or credit terms; and

–the terminals from which the fuel will be shipped and the method of shipment (ocean vessel, barge, tank truck, pipeline, etc.).

If you are not currently registered as a sales tax vendor, you must apply and receive your NYS Certificate of Authority before this application will be approved for licensing/registration. You may apply online by using the New York Business Express at www.businessexpress.ny.gov.

The Tax Department will notify you if you are required to file a bond or other acceptable security (see Bonding requirements in instructions).

Mail completed application and all required documents to:

NYS TAX DEPARTMENT

REGISTRATION AND BOND UNIT

W A HARRIMAN CAMPUS

ALBANY NY 12227-2993

If not using U.S. Mail, see Publication 55, Designated Private Delivery Services.