Free DR-176 - Florida

Application for Air Carrier Fuel Tax License

DR-176 R. 03/09
Rule 12B-5.150 Florida Administrative Code Effective 04/09

You must complete this application with appropriate attachments and receive approval by the Florida Department of Revenue before engaging in or conducting business involving fuel in the State of Florida.
1. 2. 3. 4. 5. FederalEmployerIdentificationNumber(FEIN) FEIN ­

BusinessName ___________________________________________________________ Phone No. __________________________ TradeName,D.B.A.orA.K.A. _______________________________________________ Fax No. _____________________________ Contact Person ___________________________________________________________ Phone No. _______________ ext. ______ TypeandLegalOrganization:(Pleasecheckonlyone) A) Corporation (check one): C Corp S Corp If corporation, check all boxes that apply: Wholly Owned Subsidiary of a Publicly Held

Corporation

Publicly Held Corporation Privately Held Corporation

B) Partnership (check one):

General Limited Joint Venture Single Member Multi-member

C) Limited Liability Company (check one): D) Individual/Sole Proprietorship E) Business Trust F) Governmental Agency 6.

Principal Business Location Address (cannot be a post office box) __________________________________________________ City ____________________________ County _______________________________ State ____________ ZIP ___________

Country _____________________________________________ 7.

Foreign Postal Code _____________________________________ Yes No

Doyoureceivetax-freeaviationfuelunderU.S.Customsbond?

If yes, enter the number of gallons received each month________________________________ 8. Corporation Information A) License Applicant: If filing as a corporation, list your state of incorporation: _________________________________________ List other states where your corporation has operated or is operating: _______________________________________________ B) Parent Corporation (if applicable) Parent Corporation FEIN ­

Parent Corporation Name ______________________________________________________________________________________ Parent Corporation Address____________________________________________________________________________________ City _________________________ Country ________________ County _______________________________ State ____________ ZIP ___________ Ext. ________

Foreign Postal Code ________________

Phone No. ___________________

NOTE:IfincorporatedinastateotherthanFlorida,youmustattachacertifiedcopyofthecertificateorlicense issuedbytheFloridaSecretaryofStateauthorizingthecorporationtotransactbusinessinFlorida.

9.

Personnel/Partner Information: Full name, social security number (SSN), FEIN (if applicable), and address of each DR-176 corporate officer, owner, general partner, stockholder with a controlling interest, and/or director. (You may make copies R. 03/09 of this page if additional space is needed.) A) Name ______________________________________________________ Home Address ______________________________________________ City _________________________ Country ________________ SSN FEIN ­ State ____________ ­ ­ (Individual) (Business) ZIP ___________ Ext. ________

County _______________________________

Foreign Postal Code ________________

Phone No. ___________________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________% B) Name ______________________________________________________ Home Address ______________________________________________ City _________________________ Country ________________ SSN FEIN ­ State ____________ ­ ­ (Individual) (Business) ZIP ___________ Ext. ________

County _______________________________

Foreign Postal Code ________________

Phone No. ___________________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________% C) Name ______________________________________________________ Home Address ______________________________________________ City _________________________ Country ________________ SSN FEIN ­ State ____________ ­ ­ (Individual) (Business) ZIP ___________ Ext. ________

County _______________________________

Foreign Postal Code ________________

Phone No. ___________________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________% D) Name ______________________________________________________ Home Address ______________________________________________ City _________________________ Country ________________ SSN FEIN ­ State ____________ ­ ­ (Individual) (Business) ZIP ___________ Ext. ________

County _______________________________

Foreign Postal Code ________________

Phone No. ___________________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________% Note­SocialSecurityNumbersareusedbytheFloridaDepartmentofRevenueasuniqueidentifiersfortheadministration ofFlorida'staxes.SocialSecurityNumbersobtainedfortaxadministrationpurposesareconfidentialundersections213.053 and119.071,FloridaStatutes,andnotsubjecttodisclosureaspublicrecords. 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 all 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

W A R N I N G :
Read carefully: This instrument is a sworn document. False answers could result in criminal prosecution subject to fine and/or imprisonment and denial of your application.

__________________________________________
Print, Type or Stamp Name of Notary

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

Instructions for Application for Air Carrier Fuel Tax License
Whomustregister? A commercial air carrier that operates in Florida must apply to the Department of Revenue for an air carrier fuel tax license. To obtain a license, the applicant must complete an Application for Air Carrier Fuel Tax License (Form DR-176) and furnish all documentation that the Department may require. The license must be renewed annually. Howmuchistheregistrationfee? The fee for a Florida Air Carrier Fuel Tax License is $30. The fee for renewals is also $30. WheredoIsendtheapplicationandtherequired fee? Mail this application with the required fee and the applicable surety bond(s) to: ACCOUNT MANAGEMENT / FUEL UNIT FLORIDA DEPARTMENT OF REVENUE 5050 WEST TEnnESSEE STREET BLDg E-1 TALLAHASSEE FL 32399 Donotsendcash. HowandwhendoIreportthetax? Once you have registered to collect and/or report aviation fuel tax, you will receive a monthly Florida Air Carrier Fuel Tax Return (Form DR-182). Taxes are due to the Department on the 1st day of the month following the collection period. Your return

DR-176 R. 03/09

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. We may assess penalty and interest if your return is not postmarked by the 20th. Youmustfileareturneven 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. WhendoIneedtocontacttheDepartmentof Revenue? · To file this application.

· · · ·

If your business moves. If you close your business. If you change or add a licensable business activity. If your contact person changes.

WhataremyElectronicPaymentObligations? You will be required to submit your payment by Electronic Funds Transfer (EFT) if you pay more than $20,000 in aviation 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/.

For Information and Forms
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 aviation fuel tax, call Taxpayer Services, Monday through Friday, 8 a.m. to 7 p.m., ET, at 800-352-3671 or 850-488-6800. To speak with a Department of Revenue representative, call Taxpayer Services, Monday through Friday, 8 a.m. to 7 p.m., ET, at 800-352-3671 or 850-488-6800. For a written response to your questions, write: TAXPAYER SERVICES FLORIDA DEPARTMENT OF REVENUE 5050 W TENNESSEE ST BLDG L TALLAHASSEE FL 32399-0112 Hearing or speech impaired persons may call the TDD line at 800-367-8331 or 850-922-1115. Department of Revenue service centers host educational seminars about Florida's taxes. For a schedule of upcoming seminars, · Visit us online at www.myflorida.com/dor or · Call the service center nearest you.