Form M-233T State Form 2331 (R5/ 11-07) Indiana Department of Revenue Annual Toll Road Gate Application (1) Name of Transporting Company: A. STARTING DATE: JANUARY 1, _____ B. EXPIRATION DATE: DECEMBER 31, ____ FEE: $20.00 PER GATE (3) Federal Identification Number: Address: (4) Social Security Number (If Sole Proprietor): City, State, and Zip: (5) Make of Tractor Year: (6) License Plate State: Daytime Telephone Fax Number: (7) Full Vehicle Identification Number (VIN): (8) Toll Road Gate Numbers (2) Contact Person ALLOWABLE WEIGHTS: A single axle must not exceed 22,400 pounds per axle; each axle of a tandem group may not exceed 18,000 pounds per axle; and the weight per inch width of tire measured between flanges of the rim may not exceed 800 pounds. ALLOWABLE DIMENSIONS: The category checked below applies to this permitted vehicle and load. 1 A single vehicle whose width does not exceed 12 feet, the length does not exceed 65 feet, and the height does not exceed 13 feet, 6 inches. The maximum weight, subject to axle limits, may not exceed 90,000 pounds. 2 A combination of two vehicles (tractor-trailer) whose trailer does not exceed 53 feet in length, the width of which does not exceed 12 feet, and the height does not exceed 13 feet, 6 inches. The maximum weight, subject to axle limits, may not exceed 90,000 pounds. A combination of three vehicles (tractor-trailer-trailer) whose trailers do not exceed 48 feet, 6 inches each, the width of which does not exceed 8 feet, 6 inches, and the height does not exceed 13 feet, 6 inches. The maximum weight, subject to axle limits, may not exceed 127,400 pounds. CAUTION: You must contact the Indiana Toll Road Authority to obtain a toll road certification for this type of vehicle prior to applying for this permit. 3 4 A combination of 4 vehicles (tractor and triple trailer) whose trailers do not exceed 28 feet, 6 inches each, the width of which does not exceed 8 feet, 6 inches, and the height does not exceed 13 feet, 6 inches. The maximum weight, subject to axle limits, may not exceed 127,400 pounds. CAUTION: This type of triple trailer combination is not allowed on any highway other than an Indiana toll road, except between an Indiana toll road designated make-up, break-up area and the nearest toll gate. The General Provisions and any Special Provisions, are incorporated by reference into the permit and are as fully binding upon the permittee as if they had appeared on the face of the permit. THE PERMIT IS VALID OVER STATE ROADS: All state highways, when used in conjunction with toll road travel, within 15 miles to or from the permitted Toll Gate (permits are Gate specific), but excluding: all Interstate Highways and Indiana Harbor Canal Lift Bridges. The permit is NOT valid with a special weight permit. Special Gate Exceptions GATE 101: Excluding any vehicle with an overall length in excess of 95 feet. GATE 144: Excluding State Road 1 and State Road 427. Under penalties of perjury, I declare I have examined the above information, and to the best of my knowledge and belief it is true, correct and complete. Signature Date American LegalNet, Inc. www.FormsWorkflow.com