Form AR-1R Combined Business Tax Registration

a) Are you renting/leasing the property? a) Did you purchase the inventory fixtures or equipment of an established business? Add Additional Location Add Additional Tax Type ATAP Third Party Access Aviation Tax Barge Blend Gasoline or Diesel Fuel with Alcohol or Ethanol other Petroleum Products Agricultural or Waste of such Products? Complete this line for each responsible party who is an owner partner member corporation officer or trustee Attach additional pages if needed In the case of limited partnerships complete this section for each general partner See instructions for additional information Corporation Corporation Income Distillate Special Fuels Dyed Diesel Export Fuel from Arkansas? Federal Identification Number (FEIN): (Required) Fiduciary / Trust Gasoline Government Have any Transactions in Dyed Petroleum Products? Import Fuel into Arkansas? Important Read Before Signing This registration form must be signed by a responsible party who is authorized to sign on behalf of the organization The Proprietor must sign for sole proprietorship I declare under the penalties of perjury that the information provided (including any accompanying statements) has been examined by me and to the best of my knowledge and belief is true correct and complete Liquefied Gas Liquor Long Term Rental Vehicle Tax Mixed Drink Motor Fuel Natural Gas New Business Never Registered Non Profit Off Premises Consumption On Premises Consumption Ownership Change Partnership Pipeline Private Club Residential Moving Tax Sales and Use Sell Aviation Fuel Sell Fuel to Non Licensed Reseller or Consumer? Sell Fuel to other Arkansas Licensed Distributors? Short Term Rental Tax Short Term Rental Vehicle Tax Sole Proprietor Take Ownership of Fuel at an Arkansas Terminal? Tourism Tax Truck Wholesale Vending Tax Withholding Pass Through Withholding Pension Withholding Wage 1 Do you have an Arkansas location or have inventory in Arkansas AND make sales on a retail basis? 2 Do you perform a taxable service in Arkansas? 3 Do you lease or rent tangible property in Arkansas? 4 Will the business make purchases of services or tangible personal property (e g equipment furnishings materials or supplies) from vendors located outside the state of Arkansas? a) Do you operate a business at your resident address? a) Do you operate more than one business in Arkansas? a) Have you previously held a Motor Fuel Tax License in Arkansas? a) Important Information: A $50 00 non refundable application fee is required of all Arkansas vendors on a retail or wholesale basis Out of state vendors that lease property into Arkansas or perform taxable services in Arkansas are required to pay the $50 non refundable application fee (If you answer yes to 1 2 or 3 below the fee is required ) a) Please check the applicable classification a) Please check the applicable classification a) Signature Amusement AR 1R AR 1R AMU AR 1R BPG AR 1R BRDM or AR 1R BRLAO AR 1R VEN AR1103 Are you acquiring an existing business that held a Motor Fuel Tax License? ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION Combined Business Tax Registration Form PO Box 8123 Little Rock AR 72203 8123 b) Arkansas Code Annotated 26 52 207 states that the tax liability of the former owner transfers to the new owner when the business is sold No permit will be issued to the new owner until all tax liability is paid c) The former owner of a business must surrender the permit and report and pay all taxes due by the business through the transfer date A lien will attach to the stock and fixtures to secure the State of Arkansas for delinquent taxes and is enforceable against the purchaser d) Arkansas law requires each location collecting Sales or Use Tax to register and pay the $50 00 non refundable application fee b) Date b) If yes attach a copy of your city business license or a statement that a license is not required b) If yes attach a separate schedule Include all location's names and addresses b) If yes provide a copy of the Lease Agreement (Required) Beauty Pageant Bingo/Raffle Brine Severance Brucellosis/Pseudorabies c) Please check the applicable classification c) Printed Name Catfish Feed Check One: Cigarette Cigarette Papers Construction Contact Information Corn/Grain Sorghum d) Title Distributor Distributor Only Distributor/Wholesaler Do you have Bulk Storage Facilities in Arkansas? Do you transport petroleum in any device having a carrying capacity exceeding 9 500 gallons? Estimate the number of gallons to be reported in the State of Arkansas each month For AMUSEMENT please complete and attach form For BEAUTY PAGEANT please complete and attach form For BINGO/RAFFLE please complete and attach form For MERCHANDISE VENDING please complete and attach form For Sub S Election please complete and attach form If importing or exporting Fuel what means of Transport will you utilize? If you are granted a License do you expect to: Liquor Mailing Address Manufacturer Manufacturer Manufacturer Merchandise Vending Native Brewery/Distributor Natural Gas Severance Oil Severance Other Severance Other Tobacco Products Ownership Type: (Check only one) Page 1 of 7 Page 2 of 7 Page 3 of 7 Page 4 of 7 Page 5 of 7 Page 6 of 7 Page 7 of 7 Partnership Income Physical Location Address Please check the applicable classification Please check the applicable classification Please check the applicable classification Please check the applicable classification Please check the applicable classification Please check the applicable classification Please check the applicable classification Please check the applicable classification Please check the Fuel Type you plan to import or purchase for resale or distribution in Arkansas Primary Business Activity: (Enter the NAICS code that best matches your business (see instructions) and describe your business activity Primary Processor/Producer Producer Producer Producer Producer Producer Producer Purchaser Purchaser Purchaser Purchaser Purchaser Purchaser Read instructions carefully before completing this form For assistance call (501) 682 1895 Register a new business online using ATAP at www atap arkansas gov REASON FOR SUBMITTING THIS FORM Retailer Retailer Revised 08/10/2012 Revised 08/10/2012 Revised 08/10/2012 Revised 08/10/2012 SECTION A TAX TYPES SECTION AA CORN/GRAIN SORGHUM SECTION AB RICE SECTION AC SOYBEAN SECTION AD WHEAT SECTION AE BRUCELLOSIS/PSEUDORABIES SECTION AF WASTE TIRE SECTION AG CONSTRUCTION SECTION AH TELECOMMUNICATIONS SECTION AI MERCHANDISE VENDING (PLEASE COMPLETE SUPPLEMENTAL FORM) SECTION AJ AMUSEMENT (PLEASE COMPLETE SUPPLEMENTAL FORM) SECTION AK BINGO/RAFFLE (PLEASE COMPLETE SUPPLEMENTAL FORM) SECTION AL BEAUTY PAGEANT (PLEASE COMPLETE SUPPLEMENTAL FORM) SECTION B OWNER INFORMATION SECTION C RESPONSIBLE PARTY SECTION D SIGNATURE SECTION E SALES AND USE SECTION F WITHHOLDING WAGE SECTION G WITHHOLDING PASS THROUGH SECTION H WITHHOLDING PENSION SECTION I CORPORATE INCOME (INCLUDING SUB S ELECTION) SECTION J PARTNERSHIP INCOME SECTION K MOTOR FUEL SECTION L DYED DIESEL SECTION M BRINE SEVERANCE SECTION N NATURAL GAS SEVERANCE SECTION O OIL SEVERANCE SECTION P TIMBER SEVERANCE SECTION Q OTHER SEVERANCE SECTION R BEER SECTION S LIQUOR SECTION T WINE SECTION U CIGARETTE SECTION V CIGARETTE PAPERS SECTION W OTHER TOBACCO PRODUCTS SECTION X SOFT DRINK SECTION Y BEEF SECTION Z CATFISH FEED Shipper Type #1: Shipper Type #2: Small Farm Winery Soft Drink Soybean Special Additional Taxes: Check all that apply to your type of business See instructions for detailed information on each tax Telecommunications Timber Severance Type of Registration: (Check all that apply) Waste Tire Wheat Wholesaler Wholesaler