Form 637 X 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 X: Pipeline operator or vessel operator (including certain deep-draft vessels) within the bulk transfer/terminal system.

See Treas. Reg. 48.4101-1(b)(7) and (8).

These persons are required to be registered under IRC 4101(a)(1) and Treas. Reg. 48.4101-1(c)(1)(iii) and (vii).

“X” QUESTIONNAIRE

1. Does your business qualify for the Form 637 “X” 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 _“X” 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. Does your business store or ship any fuel to which it holds title?

☐ Yes ☐ No

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

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   Is your business registered or required to be registered by state or local authorities?

☐ Yes ☐ No

If yes, list the licensing agencies and numbers and dates granted.

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   Provide the estimated annual volume of gasoline, undyed and dyed diesel fuel, and kerosene that will be shipped or imported from another country.

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   List all liquid products that are received from or delivered to a fuel terminal.

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   Provide a map of each pipeline that your business operates with the name and address of each refinery, terminal, and transfer station served by each pipeline.

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   Provide a map of each route in which the vessel operates and the name and address of each refinery and terminal served by the vessel.

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   List the identifying number of all vessels your business operates that transport taxable fuel (gasoline, diesel fuel and/or kerosene), and state their capacity. Exclude deep draft ocean-going vessels.

Vessel or Barge Number	Home Port	Capacity

9. As a bulk transport carrier (barge, vessels, and pipelines), is your business required to file Form 720-CS, Carrier Summary Report?

☐ Yes ☐ No

If no, please explain why.

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

Form 637 X Questionnaire 2 Revised Feb 2022