Form INIRP-A State of Indiana Application for the International Registration Plan State Form 4947 (R2 / 2/11) SCHEDULE A Please refer to the back for instructions. 9. Mailing Address: 16. IRP Account /Fleet Number: 17. License Year: 1. Legal Name: 18. Staggered Month: SECTION 1 2. Business Entity Type: Partnership 10. County: 11. City: 19. New Account: Yes No 3. Federal ID Number (or Social Security Number if Sole-Proprietor): 12. State: 13. Zip Code: 21. Account Contact Person’s Name: 4. Indiana Business Street Address: 14. Indiana Business Telephone Number: 22. Contact Telephone Number: 15. E-mail Address: 23. Account Fax Number: 5. County: Incorporation Sole-Proprietorship Government Owned 6. City: 7. State: Last, First and Middle Initial: 8: Zip Code: Social Security Number: Last, First and Middle Initial: Social Security Number: Below, please indicate the appropriate weight where proportional registration is sought in a jurisdiction. AK AL AR AZ BC CA CO CT DC DE FL GA IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT MX NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE QC RI SC SD SK SECTION 2 AB TN TX UT VA VT WA WI WV WY YT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 U n i t Y e a r M a k e Vehicle T y p e Axles or Seats Motor Carrier U.S. DOT Number Motor Carrier FEIN/SSN Responsible for Safety Is Lease less than 30 days? Yes/No F u e l Unladen Weight Declared Gross Weight Declared Combined Gross Weight Purchase Price Factory Price Purchase Date Owner SECTION 3 Number American LegalNet, Inc. www.FormsWorkFlow.com SECTION 1 Schedule A Instructions SECTION 3 Line 1: Enter the Legal Name as it is registered with the Indiana Secretary of State or the Indiana Department of Revenue. (The IRP Unit will register the Applicant in the same name as registered with the Indiana Secretary of State or Indiana Department of Revenue.) Column 1: Enter the Registrant assigned Unit Number or Equipment Number for the vehicle. Line 2: Enter the Business Entity Type as registered with the Indiana Secretary of State or Indiana Department of Revenue. Business Entity Types are Incorporation, Partnership, Sole Column 3: Enter the Vehicle Make using the three letter abbreviation that is shown on the vehicle title or title application. Lines 3: ship. Enter the Social Security Number if registered as a Sole Proprietorship. - Lines 4 through 8: Enter the Indiana physical address location of the place of business, where operational records can be attained and where Actual Miles are accrued. Line 9 through 13: Enter the mailing address where correspondence regarding the IRP Account is to be received by the Contact Person (designated on Line 22). Use the mailing address area on the Schedule B or BN to indicate the Fleet mailing address. Line 14: Enter the Indiana business telephone number. Line 15: Enter the email address for electronic communication with the IRP Unit. Line 16: Enter the Indiana IRP Account Number and Fleet Number. If the application is for the establishment of an new IRP Account, leave blank. Line 17: Enter the last two digits of the Registration Year which the Applicant is seeking proportional registration. Column 2: Enter the last two digits of the Model Year of the vehicle. Column 4: of Title or Title Application. Column 5: Enter the type of vehicle. Vehicle Types: TK - Truck (single), TR-Tractor, TT-Truck Tractor, RT-Road Tractor, ST-SemiTrailer, FT-Full Trailer, BS-Bus, WR-Wrecker, CG-Converter Gear. (Use only the abbreviation.) For a complete description and illustration, please refer to the IRP Manual. Enter “5ST” for Five-Year Semi-Trailer plate or “PST” for Permanent Semi-Trailer plate. Column 6: Enter the number of Axles, including axles in a tandem group. If registering a Bus, indicate the rated Seat capacity. Column 7: Enter the Motor Carrier US DOT Number of the entity responsible for the vehicle Lease Agreement. Column 8: Enter the Motor Carrier Responsible for Safety FEIN / SSN (TIN). Column 9: Enter Y or N if Lease is Less Than 30 Days. Line 18: Enter the Staggered Month of the IRP account. Column 10: Enter the Fuel Type. Fuel Types are as follows: D-Diesel, G-Gasoline, P-Propane, O-Other. (Use only the abbreviation.) Line 19: Enter an X in the appropriate box for determining if a New Account. Column 11: Enter the weight of the vehicle fully equipped for service excluding the weight of any load. Line 20: Line 21: Enter the name of the person who is responsible for conducting the Account’s busiand the Contact Person Designee. Line 22: Enter the telephone number of the Contact Person. Line 23: Enter the account Fax Number. SECTION 2 Indicate the appropriate weight in the jurisdiction for the vehicle(s) in Section 3. The weight must be the “Declared Combined Gross Weight” or the “Declared Gross Vehicle Weight” as shown in Section 3, Column 13. Column 12: Enter the total unladen weight of the vehicle plus the maximum load to be carried on the vehicle. Column 13: Enter the total unladen weight of the cominbation of vehicles plus the maximum load to be carried on that combination of vehicles. Column 14: Enter the actual purchase price of the vehicle paid by the current owner, excluding Column 15: Enter the manufacturer’s retail price excluding trade in and sales tax, including Column 16: Enter the month, day and year in which the vehicle was purchased by the current owner. Column 17: Enter the name of the titled owner, if the vehicle is not owned by the Applicant. American LegalNet, Inc. www.FormsWorkFlow.com