Indiana Department of Revenue Form INIRP-BN International Registration Plan Section 1 State Form 4949 (R4 / 12-10) New Account Schedule BN 1. Registrant Name 7. Fleet Mailing Address 2. Fleet Street Address 4. City 3. County 12. IRP Account Number 8. County 14. New Account 10. State 5. State 6. ZIP Code 9. City 11. ZIP Code Yes No 15. Type of Carrier (check only one) In Section 2, place an X in the column to the right of the jurisdictions where proportional registration is sought. * NR - Non Reciprocity Jurisdiction AB Alberta X Mileage Jurisdiction X 72 AK Alaska Mileage Jurisdiction NR X Private Carrier Exempt Commodity Carrier “For Hire” Carrier (Common Carrier) Household Goods Carrier Mileage AL Alabama 2,713 AR Arkansas 2,384 AZ Arizona 2,373 BC British Col. 35 CA California 7,054 CO Colorado 1,613 CT Connecticut 669 10 DE Delaware 238 DC Wash. D.C. FL Florida 3,073 GA Georgia 3,324 IA Iowa 1,656 ID Idaho IL Illinois 5,920 KS Kansas 1,361 KY Kentucky 1,710 MA Massachusetts 766 MB Manitoba 21 MD Maryland 1,242 ME Maine 152 MI Michigan 2,782 MS Mississippi 2,093 NB New Bruns. 16. Please designate the appropriate year for the Mileage Reporting Period of July 1, __________ through June 30, __________. 3,361 LA Louisiana 10 MN Minnesota 849 MO Missouri MT Montana 544 MX Mexico NC N. Carolina NF Newfoundland 3,538 10 3,228 NR ND N. Dakota 185 NE Nebraska NH N. Hampshire 115 NJ New Jersey 2,308 10 1,880 NS Nova Scotia NV Nevada 1,170 NY New York OK Oklahoma 2,167 ON Ontario PA Pennsylvania 6,580 PE Prince Ed. Is. RI Rhode Island 82 SC S. Carolina SK Saskatchewan 37 VT Vermont 1,392 17. If your Estimated Miles differ than those shown in Section 2 , please attach a Schedule G. 1,073 NM New Mexico UT Utah 701 2,956 NT Northwest T. NR OH Ohio 7,520 452 OR Oregon QC Quebec SD S. Dakota 219 TN Tennessee 4,470 TX Texas VA Virginia 3,373 I agree Yes No 49 2,226 Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, complete and correct, and I am providing proof of financial responsibility prior to affixing my signature hereto. 1,652 10 Section 3 Section 2 13. Fleet Number 6,641 WA Washington 1,643 IN Indiana Miles WI Wisconsin 2,334 WV West Virginia 1,080 1,075 YT Yukon Terr. NR Total Fleet Miles Date Name of your Insurance Company ( 7,650 Policy Number ) Insurance Company Phone Number NR Miles WY Wyoming Title (not the agency or group) For Official Use Only 101 Signature of Owner or Responsible Officer Address of Insurance Company American LegalNet, Inc. www.FormsWorkFlow.com Schedule BN Instructions SECTION 1 Line 1: Enter the Applicant 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 the Indiana Department of Revenue. If the name as registered with the Indiana Secretary of State or the Indiana Department of Revenue differs from the title or title application name, a Lease Agreement or title change is required.) Line 2 through 6: Enter the FLEET Street Address if different than the Indiana Business Street Address on the Schedule A. Lines 7 through 11: Enter the Fleet Mailing Address if different than the Applicant Mailing Address on the Schedule A. Each FLEET may have an independent mailing address where credentials or other correspondence regarding this FLEET is received from the IRP Unit. Line 12: Enter the Indiana IRP Account Number. Line 13: Enter the Fleet Number, if applicable. SECTION 3 Line 16: Enter the year for the Mileage Reporting Period the miles are being reported. Line 17: Submit a Schedule G with a detailed “Plan of Operation”. The Schedule BN must be signed by the responsible person. Please include the job title and date. Print or type the full name of your insurance company (not the agency or the group). Enter your policy number, and all the additional information requested. Effective January 1, 1983, Indiana law requires every Motor Vehicle registered in the State of Indiana to have proof of Financial Responsibility. Proof of Financial Responsibility includes one of the following: 1. Motor vehicle’s insurance policy 2. Self insurance (certificate from BMV required) 3. Indiana Motor Carrier Authority Number (IMCA) (PSCI) 4. $40,000 in securities or cash deposited with the Treasurer of Indiana Line 14: Enter an X in the appropriate box for determining if a New Account. Line 15: Enter the Type of Carrier. Check only one. SECTION 2 Place an X in the column to the right of the jurisdictions where proportional registration is sought. The Estimated Miles for each jurisdiction are based upon the total Actual Miles traveled by proportionally registered vehicles in the jurisdiction, during the previous Mileage Reporting Period. To use other Estimated Miles, see Section 3, Line: 22. NOTE: If qualified under 2 or 3, place your IMCA number or certificate of selfinsurance number in the policy number area on the front of this form. If qualified under 4, place the word “BOND” in the insurance company name area on the front of this form. Falsification of this information will subject you to a jail term of up to two (2) years, a fine of up to $10,000 and suspension of your driver’s license for a period of up to one year. American LegalNet, Inc. www.FormsWorkFlow.com