Form 637 Questionnaires

Applicant/Registrant Name:		EIN:	Period(s)
Agent Name:	Badge Number:			Date:
Form 637 Activity Letter “S” Questionnaire

Activity Letter S: Enterer, position holder, refiner, terminal operator, or throughputter of gasoline, diesel fuel (including a diesel-water fuel emulsion), or kerosene, or industrial user of gasoline.

REGISTRATION TESTS – ACTIVITY “S”

1. The Activity Test under §48.4101-1(f)(2).

2. The Acceptable Risk test under §48.4101-1(f)(3).

3. The Adequate Security Test under §48.4101-1(f)(4).

ACTIVITY TEST

1. Check the box(es) representing the activity(ies) and the type of taxable fuel in which the entity is engaged in or likely to become engaged in within a reasonable time.

Activity(ies)	Gasoline	Diesel Fuel	Kerosene	Other
Refiner
Importer/Enterer
Terminal Operator
Throughputter
Industrial User
Position holder
Exporter

2. Check the box(es) representing all means by which the entity receives or disposes of

taxable fuel.

Mode of Transporation	Receipts	Disposals
Barge
Pipeline
Rail
Truck
Ocean Going Vessel
In-Tank Transfers
Exchange Agreements

REFINERS

1. List the name and address of the pipeline operators, barge companies, and/or ocean-going vessel operators that supplies crude oil and identify the mode of transportation.

Name and Address of Operator(s)	Pipeline	Barge	Vessel

2. List the types of taxable fuel the refinery produces (e.g. 87 octane, #3 diesel fuel, types of gasoline blendstocks, etc) and the production capacity per day per product.

Types of Taxable Fuel Produced	Production Capacity Per Day

3. What does the entity do with transmix? Indicate how the transmix is received. Provide the name and address of the carrier(s) if not listed above (see question 1).

Name and Address of Carrier(s)	Mode of Transportation

4. Provide a schematic of each refinery the entity operates.

IMPORTER/ENTERER

1. Identify the name and address of suppliers of taxable fuel, type of taxable fuel imported, quantity imported, and the origin of the imported taxable fuel.

Supplier’s Name and Address	Taxable Fuel Imported	Quantity	Origin of Imported Taxable Fuel

2. Identify the ports of entry and location of the imported taxable fuel.

Ports of Entry	Location of Port

3. Identify the carrier(s) used to import taxable fuel and the taxable fuel imported.

Name of Carrier(s) and Address	Taxable Fuel Imported

TERMINAL OPERATOR

1. Provide the name, telephone number, and address of all terminal managers.

Name of Terminal Manager	Telephone Number	Address of Terminal

2. Is the entity a for hire terminal?

3. Does the entity dye diesel fuel at the terminal? If so, describe the dye injection system used.

4. Does the entity own any of the products in the terminal(s)? If so, specify the products owned?

5. Provide a schematic of each terminal the entity owns and/or operates.

6. Provide the names of the companies that verify the unloading of barges into terminal(s)?

7. List the names and 637 Numbers of all Position Holders in the terminal(s), and identify the taxable fuel stored.

Position Holder’s Name	637 Registration Number	Taxable Fuel Stored

8. What does the entity do with transmix? Indicate how the transmix is received. Provide the name and address of the carrier(s) if not previously listed.

Name and Address of Carrier(s)	Mode of Transportation

INDUSTRIAL USER

1. List the gasoline blendstock(s) the entity purchases or intend to purchase.

2. How will the gasoline blendstock(s) be received by the entity?

3. For what purpose will the entity be using the gasoline blendstock(s)?

4. Have any gasoline blendstock(s) been resold, or plan to be resold? If so to whom?

THROUGHPUTTER/POSITION HOLDER

1. Indicate where the entity owns or will own taxable fuel in the bulk transfer/terminal system.

Bulk Transfer/Terminal System	YES	NO
Refinery
Pipeline
Vessel
Terminal

2. List the name, address and Form 637 Registration Number of any other party who will pull taxable fuel from the entity’s position at the terminal(s). CEP or large oil companies may be exempted from this question.

Name and Address of Other Party	637 Registration Number

3. Describe the records used to determine the receipt and/or removal of taxable fuel from the terminal(s) in which taxable fuel is being stored.

Acceptable Risk Test

1. Has the entity or a related person been penalized for a wrongful act? If yes, explain. (For initial registrations, review the applicant’s responses to the questions listed in Part III, Section C, Page 2 of Form 637.)

Explanation:

Adequate Security Test

Complete Form 637 Reengineering Forms: A620, B700,and B705

1. Does the entity have both adequate financial resources and a satisfactory tax history?

A620, B700, & B705

	Form 637 Activity Letter “S” Questionnaire
	Workpaper # -1.0
	Rev. 3/2008