Indiana Department of Revenue State Form 4949 R2/ 12-06 Section 1 Form INIRP-B International Registration Plan 1. Registrant Name Schedule B 2. Fleet Street Address 4. City 7. Fleet Mailing Address 3. County 8. County 5. State 6. ZIP Code 10. State 12. IRP Account Number 13. Fleet Number 14. US DOT Number 11. ZIP Code 16. Taxpayer ID Number 9. City 15. IFTA License Number 17. Fleet Contact Person Section 2 Jurisdiction Mileage Method Jurisdiction Mileage Method Jurisdiction Mileage Method Alberta A E R Alaska NR Alabama A E R Arkansas A E R Arizona A E R British Col. A E R California A E R Colorado A E R Connecticut A E R Wash. D.C. A E R Delaware A E R Florida A E R Georgia A E R Iowa A E R Idaho A E R Illinois A E R Kansas A E R Kentucky A E R Louisiana A E R Massachusetts A E R Manitoba A E R Maryland A E R Maine A E R Michigan A E R Minnesota A E R Missouri A E R Mississippi A E R Montana A E R Mexico A E R N. Carolina A E R N. Dakota A E R Nebraska A E R Newfoundland A E R N. Hampshire A E R New Jersey A E R New Mexico A E R Nova Scotia A E R Northwest T. A E R Nevada A E R New York A E R Ohio A E R Oklahoma A E R Ontario A E R Oregon A E R Pennsylvania A E R Prince Ed. Is. A E R Quebec A E R Rhode Island A E R S. Carolina A E R S. Dakota A E R Saskatchewan A E R Tennessee A E R Texas A E R Utah A E R Virginia A E R Vermont A E R Washington NR New Bruns. For Official Use Only A E R Actual Miles 18. Fleet Contact Person Telephone Number ( ) 19. Type of Carrier (check all that apply) Private Carrier Exempt Commodity Carrier “For Hire” Carrier (Common Carrier) Household Goods Carrier Section 3 20. Please designate the appropriate year for the Mileage Reporting Period of July 1, __________ through June 30, __________. 21. Total Indiana Miles 22. If your Estimated Miles differ than those stated on Indiana’s Estimated Mileage Chart, please attach a Schedule G. 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. Signature of Owner or Responsible Officer A E R West Virginia A E R NR Miles Wyoming A E R Yukon Terr. Date Name of your Insurance Company Licensed in Indiana (not the agency or group) Policy Number Wisconsin Title Insurance Company Phone Number ( ) NR Address of Insurance Company American LegalNet, Inc. www.FormsWorkflow.com Schedule B Instructions SECTION 1 Line 1: Enter the Registrant 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.) Lines 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 the Fleet will be sent by the IRP Unit. Line 12: Enter the Indiana IRP Account Number. Line 13: Enter the Fleet Number. Line 14: Enter the US DOT Number of the Registrant. All IRP Registrants are required to obtain a US DOT Number unique to the Registrant. The US DOT Number should be in the name in which the Registrant registered with the Indiana Secretary of State or Indiana Department of Revenue. Line 15: Enter the International Fuel Tax License Number. The Registrant is responsible for providing proof of IFTA responsibility whether through the Registrant having an IFTA License or through a Lease Agreement. Line 16: Enter the Taxpayer Identification Number of the Applicant. All business entities must register with the Indiana Department of Revenue and obtain a Taxpayer Identification Number. Line 17: Enter the name of the person who is responsible for conducting the Fleet’s business with the IRP Unit. If the Contact Person is not a listed Responsible Officer of the business entity, then a Power of Attorney is required, with the signature of a Responsible Officer and the Contact Person Designee. Line 18: Enter the telephone number of the Fleet Contact Person. Line 19: Enter they Type of Carrier. Please indicate all the Carrier Types that apply to this fleet. SECTION 2 For each IRP jurisdiction in which you traveled, enter the Total Mileage of the Fleet in the jurisdictions during the appropriate Mileage Reporting Period. Please designate the mileage in the “Method” column by filling in the appropriate A, E, or R. Indicate “A” for Actual Miles. Indicate “E” for Estimated Miles. Indicate “R” for Reported Miles. SECTION 3 Line 20: Enter the year for the Mileage Reporting Period the miles are being reported. Line 21: Enter the Total Miles for Indiana whether Actual Miles or Estimated Miles. Line 22: Please submit a Schedule G with a detailed “Plan of Operation.” The Schedule B must be signed, in INK, by the responsible person. Please include the job title and date. Print or type the full name of your insurance company licensed in Indiana (not the agency or group). Enter your policy number. Print or type the address and telephone number of your insurance company. 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 NOTE: If qualified under 2 or 3, place your IMCA number or certificate of self-insurance 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 the individual’s driver’s license for a period of up to one year. American LegalNet, Inc. www.FormsWorkflow.com