Form IFTA - 1 State Form 46124 (R2/ 2-05) Indiana Department of Revenue International Fuel Tax Agreement (IFTA) New License and Renewal Application Application Fee: $25.00 Please print or type all information SECTION A: TAXPAYER INFORMATION 1. Federal Identification Number: ______ - ______________________ 2. If this business is currently registered for any Indiana tax under this ownership, enter your Indiana taxpayer identification number (TID): _____________________________ 3. Name of owner, partnership, corporation or other entity name & mailing address: Name: ________________________________________________________ Street: ________________________________________________________ City: ______________________________ State: ____________ Zip: __________ County: ________________________________________________________ 4. Is this business registered as a nonprofit entity in Indiana? 5. Check type of business organization: 6. All corporations must complete the following section, otherwise proceed to Line 7. Sole Owner Yes No Partnership Corporation Government Other Entity A. State of incorporation: _______________________________________ B. Date of incorporation: _______________________________________ C. State of commercial domicile: _________________________________ D. If not incorporated in Indiana, enter the date authorized to do business in Indiana: ______________________________________ E. Name(s) of owners, partners or officers: (Attach a separate sheet if necessary) FIRST NAME TITLE STREET CITY STATE ZIP SOCIAL SECURITY # .................................. LAST NAME .................................. 7. Accounting period and year ending date: ___________________________ 8. Name of contact person: (owner, partner or corporate officer):_________________________________________________________ 9. Contact person's telephone number: (_______) ______________________________ 10. Business trade name or DBA name and address: (P.O. Box Number cannot be used as business location address) Name: ________________________________________________________ Street: ________________________________________________________ City: ______________________________ State: ____________ County: ________________________________________________________ 11. Business location telephone number: (_______) Zip: __________ ____________________________ American LegalNet, Inc. www.FormsWorkflow.com SECTION B: APPLY FOR AN INTERNATIONAL FUEL TAX (IFTA) LICENSE: Enter the mailing address where your quarterly tax returns should be sent. Name: Street: City: State: Zip Code: 12. USDOT Number: ________________________________________ 13. Indiana IRP Account Number: _______________________________ 14. Type(s) of Motor Carrier Operation: (Check all applicable) 15. ICC Authority Number(s): 16. Type(s) of fuel consumed by Qualified Motor Vehicles: Diesel Common _____________________________ Exempt ___________________________________ Natural Gas Propane (A) Have you ever been issued an IFTA license by another IFTA jurisdiction? Yes No If Yes to (A), list the jurisdiction(s): Yes No _____ _____ _____ Gasohol Private (B) 17. Gasoline Contract _____ (C) If Yes to (A), has your IFTA license ever been suspended or revoked? (D) If Yes to (C), list the jurisdiction(s) in which your IFTA license was suspended or revoked: _____ 18. Other _____ _____ _____ Do you maintain special fuel storage (Diesel, #1 fuel oil, #2 fuel oil, etc.) in Indiana? Yes No REQUEST FOR DECALS Two (2) identically numbered IFTA decals are required for each Qualified Motor Vehicle operated. One decal must be placed on the passenger's side and one decal on the driver's side of each vehicle. Additional decals may be requested for Qualified Motor Vehicles during the calendar year. 19. Number of Qualified Motor Vehicles that need decals? ______________ GO TO NEXT PAGE For Internal Use Only Standard industrial code. Please pick a primary and any secondary code(s) that may apply. Primary Secondary Secondary Secondary American LegalNet, Inc. www.FormsWorkflow.com 20. Complete the schedule below by placing an "X" next to the jurisdictions for the following information: #1 OPERATION OF QUALIFIED MOTOR VEHICLE, #2 MAINTAIN BULK FUEL STORAGE, #3 IRP FLEETS REGISTERED #1 #2 #3 #1 #2 #3 #1 #2 #3 AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS Alaska Alabama Arkansas Arizona California Colorado Connecticut Dist of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming QC SK YT Quebec Saskatchewan Yukon Territory CANADIAN PROVINCES: AB BC LB MB NB 21. Alberta British Columbia Labrador Manitoba New Brunswick NF NS NT ON PE Newfoundland Nova Scotia N W Territory Ontario Prince Edward Is. The applicant agrees to comply with the reporting, payment, recordkeeping, and license display requirements as specified in the International Fuel Tax Agreement. The applicant further agrees that Indiana may withhold any refunds due if the applicant is delinquent on payment of fuel taxes due any member jurisdiction. Failure to comply with these provisions shall be grounds for revocation of the license in all member states. Applicant agrees, under penalty of perjury, that the information given on this IFTA application is, to the best of their knowledge, true, accurate, and complete. NOTE: This form must be signed by an owner, partner, or corporate officer listed on the front of this application or by an authorized agent. If signed by an authorized agent, a properly completed power of attorney must be attached to this application. Date: Signature: Title: Make your check for $25.00 payable to the Indiana Department of Revenue. Mail the check along with this application to: Indiana Department of Revenue Motor Carrier Services Division P.O. Box 6175 Indianapolis, IN 46206-6175 (317) 615-7345 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Revenue International Fuel Tax Agreement (IFTA) License Application Instruction Need a Handbook? There's a more convenient way to get the forms and publications you need. To print your copy of the fuel tax handbooks or forms, go to www.state.in.us/dor/mcs/ forms.html. What is IFTA? (4) Is a passenger vehicle that has seats for more than nine (9) passengers in addition to the driver. Qualified motor vehicle does not include recreational vehicles Is Indiana Your Base Jurisdiction? The International Fuel Tax Agreement (IFTA) is an agreement between member jurisdictions to simplify the reporting of motor fuel taxes. Under this agreement one tax return is filed with the base state for the fuel consumed in any member jurisdictions. The member jurisdictions include all of the United States except Alaska, Hawaii, Washington D.C., and all Canadian provinces except the Yukon and the Northwest Territories. The IFTA license offers several benefits to the interstate motor carrier. These benefits include one license, one set of credentials, one quarterly tax report, and one audit in most circumstances. These advantages all lead to cost and time savings for the interstate carrier. Indiana is your base jurisdiction for IFTA licensing and reporting interstate motor carrier activity if: (1) Your qualified motor vehicles are registered in Indiana; or (2) You have an established place of business in Indiana from which motor carrier operations are performed; or (3) You maintain the operational control and operational records for qualified motor vehicles in Indiana or can make those records available in Indiana. How to Register for IFTA Any motor carrier based in Indiana and operating one or more qualified motor vehicles in at least one other IFTA member jurisdiction may apply for an IFTA License in Indiana. What is a Qualified Motor Vehicle? A Qualified Motor Vehicle means a motor vehicle that is used, designed, or maintained for the transportation of persons or property and that: (1) Has two axles and a gross vehicle weight or registered vehicle weight exceeding 26,000 pounds or 11,797 kilograms; or (2) Has three or more axles regardless of weight; or (3) Is used in combination when the weight of such combination exceeds 26,000 pounds or 11,797 kilograms gross vehicle weight; or You must first complete the application form, IFTA-1. Send the completed form, along with the application fee of $25.00 to the Indiana Department of Revenue. Once your application is processed, you will receive one (1) set of decals for each qualified truck and one (1) IFTA license cab card for your company. Make a photocopy of the license cab card for each qualified vehicle and keep the original for your files. The license card copy must be kept in the cab of each vehicle at all times. Completing the Application Section A Line 1: Nine-digit federal employer identification number (FEIN). Line 2: Ten-digit Indiana taxpayer identification number (TID). (If you don't have one, one will be assigned to you). Line 3: Name and business address of the sole proprietor, partnership, corporation or other legal entity. American LegalNet, Inc. www.FormsWorkflow.com Line 4: Indicate whether the business is registered as a nonprofit entity in Indiana. Line 5: Indicate the type of business by checking the appropriate box. Line 6: If a corporation, complete lines A through E. Line 7: List each owner, partner, or corporate officer. If more space is needed, attach additional sheets. Line 8: The contact person should be an owner, partner or responsible officer that the Department may contact. If the contact is an authorized agent, a properly completed power of attorney must be attached to the renewal application. Line 9: Telephone number of the contact person. Line 10: Business trade name or DBA name and address. Line 19: Total number of decals needed. Requests for additional decals must be in writing and may result in an audit of your account. Line 20: Check the jurisdictions in which you will be traveling. Line 21: Sign and date your return. Enclose your payment of $25.00 made payable to the Indiana Department of Revenue. Mail to: Indiana Department of Revenue Motor Carrier Services Division P.O. Box 6175 Indianapolis, IN 46206-6175 Questions? You can write to the above address or you can call us at (317) 615-7345 from 8:00 a.m. to 4:30 p.m. Monday through Friday. Please have your taxpayer identification number available when you call. Line 11: Business location phone number. Section B: Address where you would like your tax return mailed. Line 12: The USDOT number. If you do not have one, one will be assigned to you. Line 13: Indiana IRP account number. (If you have a farm plate and are not required to have an IRP account, a copy of your farm plate registration must accompany the renewal application.) Line 14: Type of carrier operations in which you engage. Line 15: ICC Authority Number(s), if applicable. Line 16: Fuel type used in your vehicles. Line 17: Have you ever been issued an IFTA License? Line 18: Indicate whether bulk fuel is maintained for storage in Indiana. American LegalNet, Inc. www.FormsWorkflow.com