Fill and Sign the Division of Revenue S Corporation Status Njgov Form

// // // //// // //// Under penalties of perjury, I declare that I have examined this election, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. ____________________________________________________________________________________________________________________________ Signature of authorized officer TitleDate Social Security Number or Employer Identification Number for an estate or qualified trust * Share- holder’sstate of residency State of New Jersey Division of Taxation New Jersey S Corporation or New Jersey QSSS Election Check the appropriate box: …Initial S Corporation Election …New Jersey QSSS Election (See Part V) …Change in S or QSSS Corporation Shareholders IMPORTANT: This form only has to be filed once. There is no renewal required. Please Note : All changes can be filed with the S corporation final return. // // // // // Check here …if the corporation has changed its name or address in the past 12 months Federal Employer Identification Number - New Jersey Corporation Number -- Name and telephone number of corporate officer or legal representative () - Date of Incorporation State of Incorporation // Part I Corporate Information (Type or Print) Name of Corporation Mailing Address City or Town, State and ZIP Code CBT-2553 (8-05) Election Information Enter the effective date of the Federal S corporation election ________/________/________ Applied for … month day year New Jersey S corporation or New Jersey QSSS election is to be effective for tax year beginning _______/_______/_______ ending _ ______/_______/_______ month day year month day year NOTE : If this election takes effect for the first tax year the corporation exists, enter for item 2 and item 3, the month, day and year of the earliest of the following: (1) date the corporation first had shareholders, (2) date the corporation first had assets, or (3) date the corporation began doing business. If the accounting period you enter is for an automatic 52-53 week tax year, check here … Part IIShareholder’s Consent Statement - By signing this election, we the undersigned shareholders, consent (1) to the corporation’s election to be treated as a New Jersey S corporation under N.J.S.A. 54:10A-1, et seq., (2) that New Jersey shall have the right and jurisdiction to tax and collect the tax on each shareholder’s S corporation income, as defined in N.J.S.A. 54A:5-10 and (3) such right and jurisdiction shall not be affected by a change of a shareholder’s residency, except as provided in N.J.S.A. 54A:1-1, et seq. Shareholders must sign, date and provide the requested information below. For the original or initial election to be valid, the consent of each shareholder, person having a community property interest in the corporation’s stock, and each tenant in common, joint tenant, and tenant by the entirety must appear below or be attached to this form. If more space is needed, a continuation sheet reporting the exact information for additional shareholders or a second consent statement must be attached to this form. Name of each shareholder, person having a community property interest in the corporation’sstock, and each tenant in common, joint tenant, andtenant by the entirety. (A husband and wife (andtheir estates) are counted as one shareholder). Signature DateStock Owned Number of shares Dates acquired Part III Corporation’s Consent Statement - The above named corporation consents (1) to the election to be treated as a New Jersey S corporation under N.J.S.A. 54:10A-1, et seq., (2) to fulfill any tax obligations of any nonconsenting shareholder who was not an initial shareholder as required by any tax law in the State of New Jersey including the payment of tax to the State of New Jersey on behalf of such shareholder. (An authorized officer must signand date below.) Part IV Persons who are no longer shareholders of the corporation. Name of shareholder, person no longer having a community property interest in the corporation’s stock, tenant in common,joint tenant, or tenant by the entirety. (A husband and wife(and their estates) are counted as one shareholder). Date Stock Relinquished Social Security Number or Employer Identification Number for an estate or qualified trust Do not enter any shareholder who sold or transferred all of his or her stock before the election was made. Under penalties of perjury, I declare that the above, to the best of my knowledge and belief, is true, correct, and complete. _______________________________________________________________________________________________________________________________ Signature of authorized officer TitleDate * You must provide the address of any shareholder who is not a resident of New Jersey on a rider and attach it to this form. - 41 - *** Signatures must be provided *** X Under penalties of perjury, I declare that I have examined this election, and to the best of my knowledge and belief, it is true, correct, and complete. _______________________________________________________________________________________________________________________________________________ Signature of authorized officer TitleDate - 42 - INSTRUCTIONS for Form CBT-2553 Part V Qualified Subchapter S Subsidiary Election Corporation’s Consent Statement - The above named corporation consents (1) to the election to be treated as a “New Jersey Qualified Subchapter S Subsidiary”, and (2) to file a CBT-100S reflecting the $500 minimum tax liability or the $2,000 minimum tax liability if the taxpayer is a member of an affiliated group or a controlled group whose group has a total payroll of $5,000,000 or more for the privilege per iod. (An authorized offi- cer must sign and date below.) Under penalties of perjury, I declare that I have examined this election, and to the best of my knowledge and belief, it is true, correct, and complete. __________________________________________________________________________________________________________________ Signature of authorized officer TitleDate 1. Purpose- A corporation must file form CBT-2553 to elect to be treated as a New Jersey S corporation or a New Jersey QSSS or to report a change in shareholders. Check the appropriate box toindicate if this is an initial S corporation election or a change in Sor QSSS corporation shareholders or a New Jersey QSSS elec-tion. 2. Who may elect - A corporation may make the election to be treat- ed as a New Jersey S corporation only if it meets all of the follow-ing criteria: a) The corporation is or will be an S corporation pursuant tosection 1361 of the Federal Internal Revenue Code; b) Each shareholder of the corporation consents to the election and the jurisdictional requirements as detailed in Part II ofthis form; c) The corporation consents to the election and the assumption of any tax liabilities of any nonconsenting shareholder whowas not an initial shareholder as indicated in Part III of thisform. 3. Where to file - Mail form CBT-2553 to: New Jersey Division of Revenue, PO Box 252, Trenton, NJ 08646-0252 (Registered MailReceipt is suggested) 4. When to make the election - The completed form CBT-2553 shall be filed within one calendar month of the time at which a FederalS corporation election would be required. Specifically, it must befiled at any time before the 16th day of the fourth month of the firsttax year the election is to take effect (if the tax year has 3-1/2months or less, and the election is made not later than 3 monthsand 15 days after the first day of the tax year, it shall be treated astimely made during such year). An election made by a small busi-ness corporation after the fifteenth day of the fourth month butbefore the end of the tax year is treated as made for the next year. 5. Acceptance or non-acceptance of election - The Division of Revenue will notify you if your election is accepted or not accept - ed within 30 days after the filing of the CBT-2553 form . If you are not notified within 30 days, call (609) 292- 9292. 6. End of election - Generally, once an election is made, a corpora- tion remains a New Jersey S corporation as long as it is a Federal S corporation. There is a limited opportunity to revoke an electiononly during the first tax year to which an election would otherwiseapply. To revoke an election, a letter of revocation signed by shareholders holding more than 50% of the outstanding shares ofstock on the day of revocation should be mailed to the address ininstruction 3 on or before the last day of the first tax year to whichthe election would otherwise apply. A copy of the original electionshould accompany the letter of revocation. Such a revocation willrender the original election null and void from inception. 7. Initial election - Complete Parts I, II and III in their entirety for an initial New Jersey S Corporation election. Each shareholder whoowns (or is deemed to own) stock at the time the election is made,must consent to the election. A list providing the social securitynumber and the address of any shareholder who is not a NewJersey resident must be attached when filing this form. 8. Reporting shareholders who were not initial shareholders - Complete Parts I, II and III when filing this form to report any newshareholder. A new shareholder is a shareholder who, prior to theacquisition of stock, did not own any shares of stock in the S cor-poration, but who acquired stock (either existing shares or sharesissued at a later date) subsequent to the initial New Jersey S cor-poration election. If a new shareholder fails to sign a consentstatement, the corporation is obligated to fulfill the tax require-ments as stated in Part III on behalf of the nonconsenting share-holder. An existing shareholder whose percentage of stock own-ership changes is not considered a new shareholder. If the tax-payer previously had elected to be treated as a New Jersey QSSS,the new shareholder must also complete Part V. 9. Part IV should only be completed for any person who is no longer a shareholder of the corporation. You do not have to enter anyshareholder who sold or transferred all of his or her stock beforethe election was made. All changes can be filed with the S corpo-ration final return. 10. Part V must be completed in order to permit a New Jersey S Corporation to be treated as a New Jersey Qualified Subchapter SSubsidiary and remit only a minimum tax. In addition, the parentcompany also must consent to filing and remitting New JerseyCorporation Business Tax which would include the assets, liabili-ties, income and expenses of its QSSS along with its own. Failureof the parent either to consent or file a CBT-100 or CBT-100S fora period will result in the disallowance of the New Jersey QSSSelection and require the subsidiary to file and remit a CBT-100Sdetermining its own liability. Corporate Parent Company’s Consent Statement - By signing this election, the undersigned corporation consents (1) to the subsidiary’s elec- tion to be treated as a “New Jersey Qualified Subchapter S Subsidiary” and (2) to taxation by New Jersey by filing a CBT-100S or a CBT-100 and remitting the appropriate tax liability including the assets, liabilities, income, and expenses of its QSSS. Corporate Parent Name AddressFID Number CBT-2553 - Cert Mail to: (8-05) PO Box 252 Trenton, NJ 08646-0252(609) 292-9292 State of New Jersey Division of Taxation New Jersey S Corporation Certification This certification is for use by unauthorized foreign (non-NJ) entities that want New Jersey S Corporation Status. This form MUSTbe attached to form CBT-2553. Part I. Corporate Information (Type or Print) Name of Corporation: ____________________________________________________ Federal Employer Identification Number: ______ - _____________________________ Part II. Corporate Attestation By signing this statement, the corporation affirms that the corporation has not conducted any activi- ties within this state that would require the Corporation to file a Certificate of Authority in accordance with N.J.S.A. 14A :13-3. Specifically, the corporation attests that it is not transacting business in accordance with the definitions provided in statute. Print the name and title of the person executing this document on behalf of the Corporation. This person must be a corporate officer. Name: ________________________________ Title: ___________________________ Signature: _____________________________ Date: ___________________________ - 43 - Instructions for Form CBT-2553 - Cert 1. This form is to be used by non-New Jersey business entities wishing to apply for New Jersey "S" Corporation status which are not required to be authorized to transact business in accor- dance with N.J.S.A. 14A :13-3 , given below. This form is in addition to and must accompany form CBT-2553. 2. Name of Corporation: Type or print name exactly as it appears on form NJ-REG and the CBT-2553. 3. Federal Employer Identification Number (FEIN): Please enter the Federal Identification Number assigned by the Internal Revenue Service. 4. Please read the Corporate Attestation and the cited statutes for compliance. 5. Print the name and title of the corporate officer signing this document and the CBT-2553. Both documents must be signed by the same corporate officer. 6. Mail the completed forms to: New Jersey Division of Revenue, PO Box 252 Trenton, NJ 08646-0252 14A:13-3. Admission of foreign corporation (1) No foreign corporation shall have the right to transact business in this State until it shall have procured a certificate of authority so to do from the Secretary of State. A foreign corporation may be authorized to do in this State any business which may be done lawfully in this State by a domestic corporation, to the extent that it is authorized to do such business in the jurisdiction of its incorporation, but no other business. (2) Without excluding other activities which may not constitute transacting business in this State, a foreign corporation shall not be considered to be transacting business in this State, for the purposes of this act, by reason of carrying on in this State any one or more of the following activities (a) maintaining, defending or otherwise participating in any action or proceeding, whether judicial, administrative, arbitrative or otherwise, or effecting the settlement thereof or the settlement of claims or disputes; (b) holding meetings of its directors or shareholders; (c) maintaining bank accounts or borrowing money, with or without security, even if such borrow- ings are repeated and continuous transactions and even if such security has a situs in this State; (d) maintaining offices or agencies for the transfer, exchange and registration of its securities, or appointing and maintaining trustees or depositaries with relation to its securities. (3) The specification in subsection 14A:13-3(2) does not establish a standard for activities which may subject a foreign corporation to service of process or taxation in this State. - 44 - Divisio n Use O nly — DLN Sta m p Divisio n Use O nly — Da te Sta m p Se nd to : Divisio n o f Re ve nue PO Bo x 252 Tre nto n, NJ 08646-0252 1-2011 ENC LO SE FEE W ITH A PPLIC A TIO N Fo rm C M - 1 0 0 C o m b ine d C ig a re tte Lic e nse A p p lic a tio n Re ta il O ve r-the -C o unte r Ve nd ing Ma c hine Ma nufa c ture r Re p re se nta tive C he c k O ne Bo x fo r the Lic e nse De sire d Enc lo se Fe e C ig a re tte Re ta il De a le r’ s O ve r-the -C o unte r Lic e nse — 1 ye a r lic e nse C o m p le te Se c tio ns A & B b e lo w $ 50 00 C ig a re tte Ve nd ing Ma c hine Lic e nse — 1 ye a r lic e nse e a c h m a c hine C o m p le te Se c tio ns A & C b e lo w $ 50 00 e a c h C ig a re tte Ma nufa c ture r Re p re se nta tive Lic e nse — 1 ye a r lic e nse C o m p le te Se c tio ns A & D b e lo w $ 5 00 Ta xp a ye r Na m e Sta rt Da te fo r Busine ss in Ne w Je rse y Tra d e Na m e FEIN (fo r b usine sse s) So c ia l Se c urity No (fo r ind iv id ua ls) Busine ss A d d re ss Ma iling A d d re ss C he c k Typ e o f O w ne rship Fo r a ll c o rp o ra tio ns, g iv e Sta te o f Inc o rp o ra tio n: C o rp o ra tio n LLC Pa rtne rship LLP Pro p rie to rship Re p re se nta tive O the r (sp e c ify) Po int o f C o nta c t: Pho ne N o Email O W NERS’ INFO RM A TIO N ( a tta c h list if ne e d e d ) Na m e Title So c ia l Se c urity N o Ho m e A d d re ss Se c tio n B — Re ta il O ve r- the - C o unte r Lic e nse Pro v id e info rm a tio n a b o ut tho se fro m w ho m yo u p urc ha se c ig a re tte s – a tta c h list if ne e d e d $ 5000 Sup p lie r Sup p lie r’ s FEIN Sup p lie r’ s A d d re ss C ity Sta te Pho ne No Se c tio n C — Ve nd ing M a c hine Lic e nse Pro v id e info rm a tio n a b o ut the m a c hine s yo u w ill o p e ra te — a tta c h list if ne e d e d $ 5000 e a c h Sup p lie r Sup p lie r FEIN Pho ne No A d d re ss w he re m a c hine is lo c a te d C ity Sta te Se c tio n D — M a nufa c ture r Re p re se nta tive Lic e nse Pro v id e info rm a tio n o n the c o m p a ny yo u re p re se nt $ 500 C o m p a ny FEIN A d d re ss C ity Sta te Pho ne No By sig ning , sig na to ry a ffirm s tha t a ll info rm a tio n is c o m p le te a nd a c c ura te . Sho uld a ny info rm a tio n b e inc o m p le te o r ina c c ura te , the a p p lic a tio n w ill no t b e p ro c e sse d . The A p p lic a tio n Fe e m ust b e e nc lo se d to p ro c e ss the a p p lic a tio n A utho rize d Sig na ture To ta l Fe e Enc lo se d : $ Printe d Na m e Title Da te Se c tio n A — Lic e nse e Info rm a tio n C he c k o ne : Initia l A p p lic a tio n Re ne wa l A p p lic a tio n Divisio n use o nly – DLN Sta m p Divisio n use o nly – Da te Sta m p Se nd to : Ne w Je rse y Divisio n o f Ta xa tio n PO Bo x 189 Tre nto n, NJ 08695-0189 Re v 12-2013 Fo rm MFA - 1 C o m b ine d Mo to r Fue ls Lic e nse A p p lic a tio n Initial Application Change Application Renewal Application Section 1 – Business Information Federal ID Number IRS 637 Number New Jersey Tax ID Number Does your company have internet access? Yes No Business Name Webpage Address Trade Name Phone Number Fax Number Physical Address Mailing Address Books and Records Address Hours of Operation Mon. -- Tues. -- Wed. -- Thur. -- Fri. -- Sat. -- Sun. -- 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. Contact for Registration Title Telephone No Email Address Contact for Reporting Title Telephone No Email Address Site Manager Title Telephone No Email Address Individual Completing this Form Title Telephone No Email Address Section 3 – Prior Owner Information Complete if you are purchas ing an existing business. Former Business Name Former License Number Former Phone Number Former Business Address City, State, Zip Date Ownership Transferred Former Business Mailing Address City, State, Zip Date Former Business Ended Section 4 – Type of Ownership Sole Proprietorship (may include spouse) Limited Liability Partnership New Jersey Corporation Date of Incorporation : __________ Partnership Government Entity Out-of-State Corporation – State: _______ Date Registered in New Jersey: _______ Limited Partnership Trust Other (specify) ___________________________ Section 5 – Owner Information Provide information for sole proprietor, a ll partners, or principal officers of corporations or limited liability corporations ( attach rider if necessary ). Name (Last, First, M) Title Social Security Number Home Address Home Phone Number Cell Phone Number Name (Last, First, M) Title Social Security Number Home Address Home Phone Number Cell Phone Number Name (Last, First, M) Title Social Security Number Home Address Home Phone Number Cell Phone Number Name (Last, First, M) Title Social Security Number Home Address Home Phone Number Cell Phone Number Section 6 – Relationships with Other Organizations Information regarding persons aff iliated with this business who either are also af filiated or have been affiliated with another business that requires licensing u nder NJSA §54:39-101 et. seq. (attach rider if necessary). Individual’s Name Title with Applicant Date Joining Applicant Social Security Number Individual’s Home Address City, State, Zip Name of Business with which Affiliation Exists Affiliated Business FID Title Effective Date of Title Address of Business with which Affiliation Exists City, State, Zip Individual’s Name Title with Applicant Date Joining Applicant Social Security Number Individual’s Home Address City, State Zip Name of Business with which Affiliation Exists Affiliated Business FID Title Effective Date of Title Address of Business with which Affiliation Exists City, State Zip Section 7 – Types of Products Handled Check each type of product with which you will be dealing in New Jersey. Gasoline Gasohol Fuel Grade Alcohol LPG Undyed Diesel Dyed Diesel Dyed Kerosene Undyed Biodiesel Dyed Biodiesel Undyed Kerosene Aviation Fuel Other – List each other product: Section 8 – Business Activity; License Requested Check all that apply. Supplier of Motor Fuels An Application Fee of $450 is due for a 3-year license. 1. You are registered or required to be registered pursuant to Section 4101 of the Federal Internal Revenue Code of 1986 and one or more of A through E. A. You are a Position Holder in a terminal in New Jersey ( List each Terminal and its location). B You export fuel from this State ( List the states to which you export and your License N o in each state ). C. You Import as a Position Holder in another state ( List the states from which you import and your License N o in each state ). D. You Import from another Position Holder ( List the Position Holders, the Position Holder’s License N o , and the state ). E. You acquire Motor Fuel in this State by two-party exchanges (List exchange partners and their License N o ). 2. You produce Fuel Grade Alcohols in New Jersey or for import into New Jersey. Permissive Supplier of Motor Fuels An Application Fee of $450 is due for a 3-year license. You are an out-of -State Supplier who is not required to be licen sed as a Supplier in this State, but you elect to be licensed anyway. Terminal Operator An Application Fee of $450 is due for a 3-year license for each Terminal Operated. 1. You own one or more Terminals in New Jersey ( List each Terminal, state whether it is a barge, pipeline, or fixed location, and its location). 2. You control one or more Terminals in New Jersey ( List each Terminal, state whether it is a barge, pipeline, or fixed location, and its location). 3. You commingle products with those of another company ( List each company and the products commingled). Distributor of Motor Fuels An Application Fee of $450 is due for a 3-year license. 1. You acquire Fuel from a Supplier, Permissive Supplier, or another Distributor for subsequent resale. 2. You import Fuel from another state ( List the states, Suppliers, each Supplier’s License N o and the products imported ). 3. You export Fuel to another state ( List the states, customers, each customer’s License N o , and the products exported ). 4. You blend Fuels ( List the types of fuels you blend and the blendstocks used ). 5. You sell Aviation Fuel. Retailer of Motor Fuels An Application Fee of $150 is due for a 3-year license. You must file a separate MFA-1 for each retail establishment. 1. You engage in the business of selling or dispensi ng motor fuel to the consumers in this state. 2. You operate a blocked pu mp for clear kerosene. 3. You sell Aviation Fuels to the consumers. 4. You dispense LPG into on-road vehicles. Please provide the follo wing regarding your retail location. 1. What is the baseload minimum power requi rement for your station? (ensuring back up power to pumps, P.O.S system, lighting, a nd requisite safety equipment) 2. Do you have a backup generator on site? Yes No 3. If yes, please submit a description. 4. If no, is your station pre-wired for a generator? 5. Number of gasoline pumps. _______________ Average gall ons of gasoline sold during the last 12 months. ________________ 6. Number of diesel pumps. _______________ Average gallons of diesel fuel sold during the last 12 months. _____________ __ 7. Number of kerosene pumps_______________ Average gall ons of kerosene sold during the last 12 months. ________________ 8. Do you lease your retail location (if yes, please provide a copy of the lease agreement)? Yes No Transporter An Application Fee of $50 is due for a 1-year license for each conveyance licensed. 1. You transport your own fuels. 2. You transport fuels under contract as a common carrier. ( List your customers, each customer’s License No , and the fuels transported ). For each Fuel Transportation Vehicle or Ve ssel, give the following information. (Attach rider if you are licensing more than 14 vehicles or vessels ). Conveyance Type VIN or Vessel Name Conveyance Type VIN or Vessel Name Total Application Fee due fo r 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. Check all that apply. You purchase dyed fuel for use in on-road vehicles. You blend your own fuel. You pick up taxable, on-road fuel from a terminal. You recycle fuel for use on-road. You make your own fuel. You acquire taxable fuel that has not been taxed. Check each type of fuel you will consume. Gasoline or Ethanol Diesel, Biodiesel or Kerosene Dyed Diesel, Biodiesel or Kerosene Aviation Fuel Section 10 – Fuel Customers / Suppliers / Position Holders Supplier of Motor Fuels applicants list customers. Distributor of Motor Fuels applicants list suppliers. Terminal Operator applicants list position holders in your terminal(s). Retailers of Motor Fuels applicants list suppliers. Customer / Supplier / Position Holder Name Federal ID N o License N o Products Terminal No How product is received Section 11 – Transporters Hired List common carriers you will use to transport fuel. Transporter Name Point of Contact Phone Number Federal ID Number Mode Section 12 – Terminals Refer to instructions to determine which terminals must be listed ( attach rider if necessary). Terminal Code Street Address City, State, Zip Section 13 – New Jersey Storage Tank Information List storage tank information by product type ( attach rider if necessary). Product Type Address City, State Zip Total Tank Capacity Section 14 – Bond Information Complete the parts applicable to the license you are requesting. Supplier or Permissive Supplier Applicants Bond or Security must be 3 times the liability for the estimated gallons handled per month. ( minimum $25,000; maximum $2,000,000 ) List estimated gallons to be handled pe r month by product types as grouped below Gasoline Diesel & Kerosene (dyed & undyed) Aviation Gasoline Jet Fuel Check type of Security to be used Surety Bond Certificate of Deposit Letter of Credit Cash Deposit Issue of Security Instrument Number Issue Date Amount Address of Issuer City, State Zip Terminal Operator Applicants Bond or Security must be 3 times the liability for the estimated gallons handled per month. List estimated gallons to be handled pe r month by product types as grouped below Gasoline Diesel & Kerosene (dyed & undyed) Aviation Gasoline Jet Fuel Check type of Security to be used Surety Bond Certificate of Deposit Letter of Credit Cash Deposit Issue of Security Instrument Number Issue Date Amount Address of Issuer City, State Zip Distributor of Motor Fuels Applicants Bond or Security must be 3 times the liability for the estimated gallons handled per month. List estimated gallons to be handled pe r month by product types as grouped below Gasoline Diesel & Kerosene (dyed & undyed) Aviation Gasoline Jet Fuel Check type of Security to be used Surety Bond Certificate of Deposit Letter of Credit Cash Deposit Issue of Security Instrument Number Issue Date Amount Address of Issuer City, State Zip Section 15 – Notice of Election for Suppliers and Permissive Suppliers 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-issu ed 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 precollect the New Jersey motor fuel tax in acco rdance with Chapter P.L 2010. C22 on all removals from a qualified terminal where we are a position holder without regard to the license stat us 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 th at the shipments were destined for New Jersey and that New Jersey imposes the requirements under its general police powers to regula te 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. Signature Title Printed Name Date Signed Section 16 – Application to be a Qualified Distributor Pursuant to Section 54:39-121, Qualified Distributors may delay remittance of the tax precollected by their Suppliers and Permi ssive 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 EFT. We acknowledge our Suppliers’ obligations to precollect tax due on Motor Fuels from us, hold it in trust for New Jersey, and re mit the precollected tax no later than the 22 nd of the month following the taxable event. We affirm that: 1. Our company was a licensee in good standing with the State of New Je rsey 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 require ments set forth by the Motor Fuels Tax Act of 2010. We agree that in order to enable our Suppliers to m eet 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 20 th 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 Qualif ied Distributor pursuant to R. S. 54:39-101 et seq. We are qualified to delay remittance to our Suppliers of tax due until the 20 th day of the month following the taxable event. We recognize that our company, an d not our Suppliers, will be liable for penalties and interest in the event that we make remittance to our Suppliers late. We further recognize that a la te 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. Signature Title Printed Name Date Signed Section 17 – Authorizing Signature Under penalty of perjury, my signature affirms all of the following:  The information provided in this applicatio n, 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 timely payments. Inaccurate or incomplete informat ion in any section is cause for denial of the requests made in Section 15 or 16, and/or the de nial of the entire application. Signature Title Printed Name Date Signed New Jersey Form MFA-1 Instructions Complete all appropriate sections and remit this application with a check for the total application fee payable to “State of New Jersey – LMF” to: New Jersey Division of Taxation P. O. Box 189 Trenton, NJ 08695-0189 Be sure to check whether this is an Initial, Change, or Renewal Application. If you ar e a licensee and wish to note changes of Address, Activ ity, etc, check Change. Failure to provide all required data will result in automatic denial of this application. Section 1 If you already have a NJ Tax Identification Number, enter it, otherwise leave th at space blank. If you already have an IRS 637 Number, enter it; otherwise leave that space blank . The Business Name is your co mpany’s name as it appears on the Business Registration. The Trade Name is the name by which you company does business and is known in the industry. The Physical Address is your company’s location for operations in New Jersey. If there are no New Jersey locations, enter your company’s primary business location. The Mailing Address is the address the Division of Taxation can use to contact your comp any for general inquiries or notices. The Books and Records Address is the address the Division of Taxation can use to contact your company regarding reporting and payments. It is the address where tax specific inquiries will be sent. Section 2 The Contact for Registration is the individual who can answer questions regarding this application. If this individual is not an employee or owner of the company, a completed Form M-5008-R must accompany this application. The Contact for Reporting is the individual who can answer questions regarding filing of reports and issuance of payments. If this individual is not an employee or owner of the company, a comple ted Form M-5008-R must accompany this application. The Individual Completing this form is the individual who actually provides the information on the application. If this individual is not an employee or owner of the company, a completed Form M-5008-R must accompany this application. Section 3 This section is for individuals or companies who purchase an existing business. All others should enter “N/A” under Former Business Name and leave all other spaces in Section 3 blank. Section 4 Check the box that applies and leave all others blank. If you check New Jersey Corporation, you must give the Date of Incorporation. If you check Out of State Corporation, you must give the state of in corporation and the Date Registered in New Jersey. If you check Other, you must give the type of ownership. Section 5 You must provide all requested information for the owner, owner and spouse, all partners, or all principal officers. If there are more than four partne rs or principal officers, you must write “See Rider Attached” in the first space and provide the information on a separate sheet. Section 6 Provide this information for an y owner, officer, or employee who operated, managed, or reported for another company that required a Motor Fuels license of any type. Section 7 Check each type of product you will possibly handle in New Jersey. If you check “Other”, you must give each other product. Section 8 Check one or more of the licen se types highlighted. For each license you request, you must be able to check one or more of the numbered boxes below that license type. You must pay the application fee for each license requested. Enter the total amount due for all licenses requested at the end of this section. You may write one check for the total due for all licenses requested. Make the check payable to State of New Jersey – LMF . Section 9 Complete this section if you are an end user who picks up fuel in a terminal or if you receive , produce, or blend fuel that has not been taxed. Section 10 Provide the information requested for the companies with whom you do business. If you deal in more than one product with a particular co mpany, list it once for each type of product. Under “How product is received”, state how your company receives control or possession of the products listed. For instance, pipeline, rack, rail, barge, etc. Section 11 Provide the information request ed for each transporter hired by your company. If you use your own modes of transport, write “Own means of transport” in the first space, and apply for a Transporters License. If you neither provide modes of transport no r hire transporters, write “N/A” in the first space. Section 12 Suppliers – Provide the requested information for New Jersey terminals in which you are a position holder and any out- of-state terminals in which you are a position holder and will collect the New Jersey tax on all removals destined to New Jersey. Permissive Suppliers – Provide the requested information for any out-of-state terminal in which you are a position holder and agree to precollect the New Jersey tax on all removals destined for New Jersey. Terminal Operators – Provide the requested information for the New Jersey terminal(s) you operate. Section 13 Please furnish the requested info rmation for all storage tanks you have in New Jersey. It is not necessary to list individual tanks. Show the total storage capacity for each product type for each location. If you have no storage in New Jersey, write “N/A” in the first space. Section 14 Complete the sections appropriate for the type of license you are requesting. If you are requesting more than one license, you will need a separate bond for each license. Section 15 This section is for Suppliers an d Permissive Suppliers only. Suppliers may complete this section if they choose. Their choice will not affect the rest of the application. Permissive Suppliers must complete this section, or the application will be denied. Other applicants should write, “N/A” in the signature space. Section 16 This section is to be completed by Distributor applicants who desire recognition as a Qualified Distributor. All others should write, “N/A” in the signature space. A Distributor applicant’s choice not to apply for recognition as a Qualified Distributor will not affect the rest of this application. Section 17 Only an individual listed in Section 5 of this application may sign this application. Without an appropriate signature, this application cannot be processed.