INDIANA DEPARTMENT OF REVENUE Indiana Revenue Form Departmental Use Only MOTOR CARRIER SERVICES DIVISION MCS-1789 Total Gallons CLAIM FOR PROPORTIONAL USE CREDIT State Form 49868 Rev.02/07 Total Miles Indiana Amount Paid QTR ________ YR _________ Total Amount Paid CLAIMANT’S NAME: Interstate or Indiana US DOT Number: Non-Indiana Based IFTA Number: Indiana TID Number: COMPLETE THIS SECTION ONLY IF CHANGING ADDRESS OR TELEPHONE NUMBER Street Address: City: State: Zip: Telephone Number: ( ) You Must Submit With This Claim For Credit MCFT-101/IFTA-101 or Out of State Return Please refer to instructions before proceeding. Attach additional sheets if necessary. 1 2 Enter Vehicle Number of Vehicles Type Codes (See Instructions) 3 Eligible Miles Traveled 4 Eligible Gallons Consumed (Use Whole Gallons) 5 6 7 Proportional Exempt Use Exempt Gallons Percentage Col.4 x Col.5 (See Instructions) (Use Whole Gallons) 8 Refund Claimed Col. 6 x Col.7 Tax Rate % .27 $ % .27 $ % .27 $ % .27 $ % .27 $ % .27 $ % .27 $ % .27 $ Total Refund Due $ Applicant agrees, under penalty of perjury, that the information given on this form is, to the best of their knowledge, true, accurate, and complete. The applicant further attests that the attached quarterly tax return is a true and accurate copy of the return filed with the based jurisdiction. This form must be signed by an owner, partners, or corporate officer or by an authorized agent. If signed by an authorized agent, a properly completed power of attorney must be attached to this form. Mail the completed form to the Indiana Department of Revenue with your quarterly return. Signature of Taxpayer or Authorized Agent: Typed or Printed Name: Title: Date Signed: Telephone Number: ( ) American LegalNet, Inc. www.FormsWorkflow.com Claim for Proportional Use Credit information and instructions The claim for credit must be completed only by companies, sole proprietorships, partnerships, or other legal entities that have been previously certified by the department, which are seeking a refund of taxes paid on motor fuel consumed in a motor vehicle which has a common fuel reservoir used to propel the motor vehicle along the highway and for some other commercial purpose. Column 1: Enter the vehicle type code. (shown on last page) Column 2: Enter the number of vehicle(s) listed in column 1. The number of vehicle(s) listed here must match the number on the certification approved by the department. Vehicle(s) additions and/or deletions must be indicated on this form in the area for such actions. Only the certification vehicle(s) and the vehicle(s) added in the appropriate area will be considered for the claim. Column 3: Enter the total number of eligible miles traveled in the state of Indiana by the vehicle(s) shown in Column 1 for the quarterly tax reporting period. Column 4: Enter the total number of eligible whole gallons consumed in Indiana by the vehicle(s) shown in Column 1 for the quarterly tax reporting period. Column 5: Enter the exempt percentage (indicated on the list of percentages) by vehicle(s) type in Column 1. Column 6: Enter the proportional use exempt gallons by multiplying Column 4 by Column 5. Column 7: Tax Rate is .27. Column 8: To calculate your tentative refund amount, multiply Column 6 by Column 7. MOTOR CARRIER FUEL TAX AND SURCHARGE TAX In order to receive a proportional use exemption credit for motor carrier fuel and surcharge tax, your quarterly return must be submitted with the proper payment. Quarterly returns filed late (the due date is shown on the quarterly return) or failure to submit the quarterly return (MCFT-101 or IFTA-101) with payment will result in denial of your claim for credit. **NON-INDIANA CARRIERS** If you submit your quarterly tax return to a state/jurisdiction other than Indiana, a copy of that quarterly report must be submitted with your Claim for Proportional Use Credit form. No claim for credit forms can be processed without the quarterly tax return for the tax quarter in which the proportional claims are being made. The department may require that any person, licensed or unlicensed, provide any additional proof that the department deems necessary. Failure to provide verification will result in the denial of the claim form. If you operate a type of vehicle(s) for which a proportional use credit should be allowed, and it is not listed or is listed and you have proof that the vehicle(s) is entitled to a different percentage than indicated on the chart, please contact our office at (317) 615-7345 for assistance in determining the allowable percentage. Indiana Department of Revenue Motor Carrier Services Division 5252 Decatur Blvd. Ste. R Indianapolis, IN 46241-9524 American LegalNet, Inc. www.FormsWorkflow.com CODE 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Air Conditioning Unit for Buses ...................................................10% Bookmobile ..................................................................................35% Boom Trucks-Block Boom ...........................................................20% Bulk Feed Trucks .........................................................................15% Car Carrier with Hydraulic Winch ................................................10% Carpet Cleaning Van ...................................................................15% Cement Mixers ............................................................................30% Distribution Truck-Hot Asphalt .....................................................10% Dump Trailers ..............................................................................15% Dump Trucks ...............................................................................23% Fire Truck ....................................................................................48% Leaf Truck ....................................................................................20% Lime Spreader .............................................................................15% Line Truck-Digger/Derrick, Aerial Lift Truck .................................20% Milk Tank Trucks ..........................................................................30% Mobile Cranes .............................................................................42% Pneumatic Tank Truck .................................................................15% 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 71 72 Refrigeration Truck......................................................................... 15% Salt Spreader-Dump with Spreader ............................................... 15% Sanitation Dump Trailers............................................................... 15% Sanitation Truck ............................................................................. 41% Seeder Truck.................................................................................. 15% Semi Wrecker ................................................................................ 35% Service Truck with Jackhammer, Pneumatic Drill .......................... 15% Sewer Cleaning Truck Sewer Jet, Sewer Vactor ........................... 35% Snow Plow ..................................................................................... 10% Spray Truck .................................................................................... 15% Super Sucker ................................................................................. 90% Sweeper Truck ............................................................................... 20% Tank Trucks .................................................................................... 24% Tank Transport ............................................................................... 15% Truck with Power Take Off Hydraulic Winch .................................. 20% Wrecker.......................................................................................... 10% Insulation Van with Blower ............................................................. 50% Auxiliary Power Unit (APU) ..............................................................4% Stone Slinger .................................................................................35% Please use the code number when listing the vehicles on the Certification and all Claims for Credit forms. Also use these codes when adding/deleting vehicles quarterly. Please Add and/or Delete Vehicles in this area. Only vehicles on the processed and approved certification application and on this list are eligible for claims for credit. If you require additional spaces, please attach a sheet that includes all of the information shown below. Designate whether adding or deleting a vehicle by placing a check ( ) in the appropriate column. A D Vehicle Code Vehicle Identification Number Power Units Only Vehicle Type TK or TR Vehicle Make American LegalNet, Inc. www.FormsWorkflow.com