Form 637 M Questionnaire OMB_Rev_Feb_2022

Name:		EIN:
Address:		637 Reg No.:
City, State, Zip:		OMB No.:	1545-1835

In addition to the Form 637 General Questionnaire, please answer the following questions specific to this activity. (Attach additional sheets, if needed.)

Activity Letter M: Blender of gasoline, diesel fuel (including a diesel-water fuel emulsion), or kerosene, producing a blended taxable fuel outside the bulk transfer/terminal system, including blenders of alcohol fuel mixtures, alternative fuel mixtures, biodiesel mixtures, and renewable diesel mixtures. See Treas. Reg. 48.4081-3(g) and 48.4081-1(c).

Blenders are required to be registered under IRC 4101(a)(1) and Treas. Reg. 48.4101-1(c)(1)(i).

"M" QUESTIONNAIRE

1. Does your business qualify for the Form 637 “M” Registration?

☐ Yes ☐ No

• If yes, please complete questions below and return this form.

• If no, please sign the statement below, date, and return this form.

I request my Form 637 _“M” Registration be denied or revoked as I am no longer engaged in this activity.

____________________________________ __________________

Printed Name Title

____________________________________ __________________

Signature Date

Note: This request must be signed by a person with authority to bind the applicant or registrant. Refer to Form 637, Application for Registration (For Certain Excise Tax Activities), General Instructions, under the Signature section for additional guidance.

1. Is your business blending a taxable fuel outside the bulk transfer/terminal system?

☐ Yes ☐ No

If yes, list the estimated annual volume of blended taxable fuel that your business will produce.

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   List all locations and storage facilities where gasoline, diesel fuel, kerosene, or products used in blending (biodiesel, ethanol, etc.) are stored. List the expected volume (in gallons) of each product that will be sold or blended by each facility.

Name and Address of Facility	Tank #	Product Stored	Expected Annual Volume

Indicate with an (*) any facility that sells fuel at retail.

4. List the additives and products (biodiesel, ethanol, etc.) that will be used for blending with gasoline, diesel fuel, or kerosene.

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   List name and address of all fuel and blending component (additives, biodiesel, ethanol, etc.) suppliers, type and estimated annual volume of product purchased.

Name and Address of Suppliers	Type of Product Purchased	Estimated Annual Volume

Indicate with an (*) those which will be tax-free transactions

6. Does your business have purchase contracts with the above suppliers?

☐ Yes ☐ No

If yes, please have copies available for review.

7. Where will the above products be picked up?

   Supplier’s Name	Supplier’s Address

8. If your business is not blending, who is your business purchasing the blended product from?

Supplier’s Name and Address	Product	% in Blend by Volume	Annual Gallons Purchased *

* If new applicant, anticipated annual gallons purchased

9. List the name and address of customers that your business sold blended taxable fuel and type of product sold.

Customers Name and Address	Type of Product Sold

Indicate with an (*) those which will be tax-free transactions

10. If your business is blending biodiesel with diesel fuel, is your business using ☐agri-biodiesel or ☐other than agri-biodiesel? (check the appropriate box(es))

11. Does your business own or operate any retail stations?

☐ Yes ☐ No

If yes, list the locations.

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    Does your business have a position in any terminal?

☐ Yes ☐ No

If yes, list the locations.

13. 
    
    

    
    
    

    
    
    

    
    
    

    Does your business store any fuel to which it does not hold title?

☐ Yes ☐ No

If yes, where is this inventory stored? For whom is, it stored? Are separate inventory records maintained?

14. 
    
    

    
    
    

    Does your business own fuel transports?

☐ Yes ☐ No

If yes, list Vehicle Identification Number (VIN), Gross Vehicle Weight (GVW), fuel transported and capacity of each.

VIN	GVW	Fuel Transported	Capacity

15. List the name and phone number of a person whom we can contact about this application/registration.

Form 637 M Questionnaire 5 Revised Feb 2022