Cancellation Of License {MF-627}

State Form 49115 (R6 / 2-14) MF-627 Indiana Department of Revenue Cancellation of License Company Name DBA Address City State ZIP Code Please provide a license number for all license types you want to cancel. 1. Effective Date of Cancellation: ______________________________________________________________________________ 2. Gasoline Distributor's License Number: _______________________________________________________________________ 3. Oil Inspection Distributor's License Number: ___________________________________________________________________ 4. Aviation Fuel Dealer's Number: _____________________________________________________________________________ 5. Marina Fuel Dealer's Number: ______________________________________________________________________________ 6. Special Fuel Importer's License Number: _____________________________________________________________________ 7. Special Fuel Transporter's License Number: ___________________________________________________________________ 8. Special Fuel Exporter's License Number: _____________________________________________________________________ 9. Special Fuel Supplier's License Number: _____________________________________________________________________ 10. Special Fuel Permissive Supplier's License Number: ____________________________________________________________ 11. Special Fuel Terminal Operator's License Number: _____________________________________________________________ 12. Special Fuel Blender's License Number: ______________________________________________________________________ 13. Special Fuel Dyed User's License Number: ___________________________________________________________________ 14. Special Fuel Eligible Purchaser's License Number: _____________________________________________________________ 15. Petroleum Severance License Number: ______________________________________________________________________ 16. Indiana Gasoline Use Tax License Number: ___________________________________________________________________ 17. Gasohol Blender License: _________________________________________________________________________________ 18. Aviation Fuel Excise Number: ______________________________________________________________________________ Taxpayer Identification Number (TID): ____________________ Signature: _________________________________________ Title: ______________________________________________ Date Signed: ___________________________________ Printed Name: __________________________________ Telephone Number: ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Form MF-627 You must return the fuel tax license card(s) to the Indiana Department of Revenue when you cancel a fuel tax license. For assistance, call (317) 615-2625 or email the Fuel Tax Section at fetax@dor.in.gov. Please mail the completed form and license card(s) to: Indiana Department of Revenue Fuel Tax, Bonds and Licensing Section P.O. Box 6114 Indianapolis, IN 46206-6114 American LegalNet, Inc. www.FormsWorkFlow.com