Free DR-166 - Florida

FloridaPollutantTaxApplication

DR-166 R.03/09
Rule 12B­5.150 FloridaAdministrativeCode Effective04/09

What are pollutants? "Pollutants" includes any petroleum product as defined below, as well as crude oil, pesticides, ammonia, chlorine, and solvents. The definition does not include liquefied petroleum gas, medicinal oils, and waxes. Products intended for application to the human body, for use in human personal hygiene, or for human ingestion are not pollutants, regardless of their contents. "Petroleum Product" means any refined liquid commodity made, or partially made from oil or gas, or blends or mixtures of oil with one or more liquid products or by-products derived from oil or gas, or blends or mixtures of two or more liquid products or by-products derived from oil or gas. "Petroleum Product" also includes, but is not limited to motor gasoline, gasohol, aviation gasoline, naphtha-type jet fuel, kerosene-type jet fuel, kerosene, distillate fuel oil, residual fuel oil, naphtha of less than 400 Fahrenheit for petroleum feed, special naphthas, motor oil, lubricants, road oil, still gas, unfinished oils, motor gas blending components, including ethanol when used for such purposes, and aviation gas blending components. What is taxable? · Solvents (organic compounds in liquid form): acetamide, acetone, acetonitrile, acetophenone, amyl acetates (all), aniline, benzene, butyl acetates (all), butyl alcohols (all), butyl benzyl phthalate, carbon disulfide, carbon tetrachloride, chlorobenzene, chloroform, cumene, cyclohexane, cyclohexanone, dibutyl phthalate, dichlorobenzenes (all), dichlorodifluoromethane, diethyl phthalate, dimethyl phthalate, dioctyl phthalate (di2-ethyl hexyl phthalate), n-dioctyl phthalate, 1,4-dioxane, petroleumderived ethanol, ethyl acetate, ethyl benzene, ethylene dichloride, 2-ethoxy ethanol (ethylene glycol ethyl ether), ethylene glycol, furfural, formaldehyde, n-hexane, isophorone, isopropyl alcohol, methanol, 2-methoxy ethanol (ethylene glycol methyl ether), methyl tert-butyl ether, methylene chloride (dichloromethane), methyl ethyl ketone, methyl isobutyl ketone, mineral spirits, 140-F naphtha, naphthalene, nitrobenzene, 2-nitropropane, pentachlorobenzene, phenol, perchloroethylene (tetrachloroethylene), stoddard solvent, tetrahydrofuran, toluene, 1,1,1-trichloroethane, trichloroethylene, 1,1,2-trichloro-1,2,2trifluor-ethane, xylenes (all) · Motoroilandotherlubricants · Ammonia · Chlorine · Gasolineandgasohol · Otherpollutantsincluding, but not limited to, aviation gasoline and gas blending components, naphtha-type jet fuel, kerosenetype jet fuel, kerosene, diesel fuel, distillate fuel oil, residual fuel oil, naphtha of less than 400 degrees F for petroleum feed, special naphthas, road oil, still gas, unfinished oils, motor gas blending components (e.g., ethanol when used for blending), waste oils, pesticides (liquid or solid) Who must register? You must register if you produce in Florida, import into, or cause to be imported into Florida, taxable pollutants for sale or use, and are not currently licensed under Chapter 206, Florida Statutes.

How much is the registration fee? We require an annual $30 registration fee. You must register with the Florida Department of Revenue before first producing or importing pollutants in Florida. Arethereadditionalfees? Most applicants are required to post a bond. The bond shall equal three times the average monthly pollutants tax paid or due during the past 12 months, not to exceed $100,000. If the three-month tax liability is less than $50, we do not require a bond. New registrants should base their bond on a reasonable estimate. Applicants who do not hold a valid motor fuel, diesel fuel, or aviation fuel tax license issued pursuant to Parts I, II, or III of Chapter 206, F.S., are required to undergo a background investigation. The Department's investigation verifies the information supplied by the applicant on the Florida Pollutant Tax Application and the Investigative Background questionnaire. The Department will also conduct an investigation on the local and national level for criminal and civil violations. A local and national fingerprint check will be conducted by the Florida Department of Law Enforcement and the Federal Bureau of Investigation. The cost will be billed to the applicant. When is tax due? Taxes are due to the Department on the 1st day of the month following the collection period. Your return is late if delivered or postmarked after the 20th day of the month following the collection period. If the 20th is a Saturday, Sunday, state holiday, or federal holiday, your return must be postmarked or delivered to the Department by the next business day. If you are subject to the tax, you must file a monthly Pollutants Tax Return (Form DR-904), even if no tax is due. If you make a tax payment using electronic funds transfer (EFT), transmit your payment before 5:00 p.m., ET, on the banking business day prior to the 20th. How is the collected tax managed? The tax collected is managed under four trust funds: Coastal Protection, Water Quality Assurance, Inland Protection, and Hazardous Waste. Where do I mail this application and registration fee? Account Management/Fuel Unit Florida Department of Revenue 5050 West Tennessee St. Bldg E-1 Tallahassee FL 32399 How do I get more information? ¸ For assistance with this application, call Account Management/ Fuel Unit, Monday through Friday, 8 a.m. to 5 p.m., ET, at 850-414-8411. ¸ Information and forms are available on our Internet site at www.myflorida.com/dor ¸ For general information about pollutant tax, call Taxpayer Services, Monday through Friday, 8 a.m. to 7 p.m., ET, at 800-352-3671 or 850-488-6800. ¸ Hearing or speech impaired persons may call our TDD line at 800-367-8331 or 850-922-1115.

InstructionsforCompletingFormDR-166
WhataremyElectronicPaymentObligations? You must submit your payment by Electronic Funds Transfer (EFT) if you pay more than $20,000 in pollutants tax between July 1 and June 30 of any given year. You may obtain additional information on electronic filing and/or enroll for EFT on the Department's Internet site at www.myflorida.com/dor/. Questions 1-6 Business Information ­ Provide the business name, owner's name(s), Federal Employee Identification Number, location address, mailing address, and type of organization requesting the license. Question 7 Corporate or Partnership Information - Provide the name, home address, social security number, and percent business interest or corporate title of each corporate officer, partner, director, and stockholder with controlling interest. Do not complete question 7 if you are an individual proprietor. Questions 8 Contact Person's Name - Enter the name, phone number, and fax number of a contact person who could answer questions about this application. Question9 Type of Application - Indicate the application type you are filing. If you are a new applicant or business, enter the date your business started. If you have had a change in your legal entity status, enter the date of the change and your previous pollutants license number. Question 10 Nature of Business - Indicate what your business will do and which taxable pollutants are included. You may check more than one box. Question 11 Storage Information - List the type of pollutant, location of the storage facility, and estimated volume of taxable units imported, produced, or sold in Florida. Attach additional sheets if necessary. Question 12 Supplier Information - List the name and license number of all your suppliers of pollutants. Attach additional sheets if necessary. Question 13 Carrier Information - List the model, total tank capacity, year, and vehicle identification number (VIN) of all trucks, barges, boats, or other equipment used to transport pollutants on the highways or waterways of Florida. Attach additional sheets if necessary. Cab cards will be issued for each motor vehicle or other transportation equipment. Question 14 Secretary of State Certificate - If you are a corporation, list the state of incorporation. List the name, address, and telephone number of the individual who will accept service in Florida. You must attach a certified copy of the certificate authorizing your corporation to transact business in Florida issued by the Florida Secretary of State. Question 15 Bonding Requirements - Indicate the amount of the surety bond enclosed. If you are currently operating as a producer or importer, your bond amount is three times the average monthly pollutants tax paid or due during the preceding 12 calendar months. If you are a new registrant, your bond amount must be three times your projected monthly tax liability. The estimate will depend on the quantity and tax rate of the pollutant you produce or import during an average month. For example: You expect your new business to import on the average 420,000 gallons (or 10,000 barrels) of petroleum derivatives a month. Petroleum derivatives are taxed at 2 cents a barrel under Coastal Protection, 5 cents a barrel under Water Quality, and 80 cents a barrel under Inland Protection. Thus, your monthly tax liability would be $8,700 ($200 for Coastal Protection, plus $500 for Water Quality, plus $8,000 for Inland Protection). Your bond would be three times your monthly tax liability or $26,100 (3 times $8,700). Your bond amount will not exceed $100,000. We do not require a bond if your three-month tax liability is less than $50. Affidavit,Signature,andNotarialCertificate Read the affidavit and sign your application. An original signature is required. A photocopy, facsimile, or stamped signature is not acceptable. You must have your application notarized.

Filing Tips
Whencompletingyourapplication,besureto provide: All information requested on Form DR-166. Application fee of $30. Your social security number (SSN) or federal employer identification number (FEIN). Social Security Numbers are used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. Social Security Numbers obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records. Original signature by an officer or an authorized representative and properly notarized. We will not accept a photocopy, facsimile, or stamped signature. A list of all suppliers of pollutants, if known, and their license number, if applicable. A copy of the certificate issued by the Florida Secretary of State showing the corporation is authorized to transact business in Florida. A surety bond (see Question 16 on the application and detailed instructions for computing the bond amount). Do not obtain a surety bond if your average monthly tax liability, multiplied by three, is less than $50. Your surety bond must be signed and accompanied by a Power of Attorney from a Florida resident agent.



FloridaPollutantTaxApplication
Mail this application with $30 fee to: Account Management/Fuel Unit Florida Department of Revenue 5050 West Tennessee St. Bldg E-1 Tallahassee FL 32399
License Number Approval Date

DR-166 R.03/09

ForDORUseOnly
Examiner's Initials

1. BusinessName: __________________________________________________________________________________________________ 2. Owner'sName: ___________________________________________________________________________________________________
(Individual, Corporation, Partnership, Limited Liability Company)

3. FederalEmployerIdentificationNumber:

­
(Street Address)

4. LocationAddress: ________________________________________________________________________________________________ __________________________________________________________________________________________________________________
(City, State, ZIP)

5. MailingAddress: __________________________________________________________________________________________________
(if other than location address) (Street Address)

__________________________________________________________________________________________________________________
(City, State, ZIP)

6.

TypeandLegalOrganization: (Please check only one) A) Corporation (check one): C Corp S Corp B) Partnership (check one): If corporation, check any of the appropriate boxes that apply: Wholly Owned Subsidiary of a Publicly Held Corporation Multi-member Publicly Held Corporation Privately Held Corporation C) Limited Liability Company (check one): D) Individual/Sole Proprietorship E) Business Trust F) Governmental Agency Single Member

General Limited Joint Venture

7. CorporateorPartnershipInformation (If you are an individual proprietor, do not complete this section):
Name* HomeAddress(includeCity,State,ZIP) SocialSecurityNumber Percent Business Interest orCorporateTitle

*Full name of corporate officers, partners, directors, and stockholders with a controlling interest (attach separate sheets if necessary) Note- Social Security Numbers are used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. Social Security Numbers obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.

8. ContactPerson'sName: ____________________________________Phone: (______)____________Fax: (_______)_________________ 9. TypeofApplication:



New Applicant/Business Legal Entity Change

Date Business Began or Will Begin: ________________________________ Date of Change: _________________________________________________

Previous Pollutants License Number: ___________________________________________________________ 10. NatureofBusiness:This business will (check all that apply): Produce Import or cause to be imported (into Florida) Ammonia Crude Oil Pesticides Solvents Export Be entitled to a refund on the following taxable pollutants: Petroleum Products Motor Oil or Other Lubricants Chlorine Perchloroethylene

Other (specify) _____________________________________________________________________________________________

11. StorageInformation:Listthetypeofpollutant,locationofstoragefacility,andestimatedvolumeoftaxableunits imported,produced,orsoldinFlorida.
Type of Pollutant Location of Storage Facility TaxableUnits

12. Supplier Information: List all suppliers of pollutants.
NameofSupplier LicenseNumber

13. CarrierInformation:Listthemodel,totaltankcapacity,year,andvehicleidentificationnumber(VIN)ofalltrucks,barges, boats,orotherequipmentusedtotransportpollutantsonthehighwaysorwaterwaysofFlorida. Cab cards will be issued for each motor vehicle or equipment used for transporting taxable pollutants.
Model TotalTankCapacity Year VIN

14. FloridaSecretaryofStateCertificate:If a corporation, list the state of incorporation: ____________________________________ List the name, address, and telephone number of the individual designated to accept service in Florida: _____________________ __________________________________________________________________________________________________________________
Attach a certified copy of the certificate authorizing such corporation to transact business in Florida, issued by the Florida Secretary of State.

15. Bonding Requirements A surety bond in the amount of $______________________is enclosed. An assigned time deposit or an irrevocable letter of credit may be accepted in lieu of a bond. If already operating as a producer or importer of pollutants, your bond amount will be three times the average monthly pollutants tax paid or due during the preceding 12 calendar months. If a new registrant, your bond amount will be three times your estimated projected monthly tax liability. The projection will depend on the quantity and tax rate of the pollutant you produce or import during an average month. See detailed instructions for example. Yourbondwillnotexceed$100,000.Ifyourthree-monthtaxliabilityislessthan$50,abondisnotrequired. AffidavitofApplicant(s) I, the undersigned individual(s), or if a corporation for itself, its officers, and directors, hereby swear or affirm under penalty of perjury as provided in section 837.06, Florida Statutes, that I am duly authorized to make the foregoing application and that the application and attachments are true and correct representation(s) of the premises to be licensed. If licensed, I agree that the place of business may be inspected and searched, during business hours or at any time business is being conducted on the premises, by officials and agents of the Department of Revenue for the purposes of determining compliance with Chapter 206, F.S.
Sworn to (or affirmed) and subscribed before me State of_____________ County of ________________________________ this ____________ day of ___________________ , ____________ .

_________________________________________________________
Signature of Applicant

__________________________________________
Signature of Notary Public

_________________________________________________________
Print or Type Applicant's Name

__________________________________________
Print, Type or Stamp Name of Notary

Personally Known __________ or Produced Identification __________ Type of Identification Produced ___________________________________