Indiana Department of Revenue MCFT-1 State Form 49870 (R5/2-05) Intrastate Motor Carrier Fuel Tax Annual Permit Application and Renewal Annual Fee: $25.00 Please print or type all information Section A 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 and address of owner, partnership, corporation, or other entity. Name: Street: City: State: Zip: County: 4. Is this business registered as a nonprofit entity in Indiana? Yes No 5. Type of business organization: Corporation Government 6. All corporations must complete the following section, otherwise go to Line 7. Sole owner Partnership A. Date of incorporation: C. State of commercial domicile: D. If not incorporated in Indiana, enter the date you were authorized to do business in Indiana: E. 7. State of incorporation: B. Other Accounting period and year ending date: Name(s) of owners, partners, or corporate officers: (Attach a separate sheet if necessary) Last Name First Name Title Street City State Zip Social Security # 8. Name of contact person (owner, partner, or corporate officer): 9. Contact person's telephone number: ( 10. Business trade name or D.B.A. name and address (PO Box number cannot be used as business location address): ) Name: Street: City: State: Zip: County: 11. Business location telephone number: ( ) American LegalNet, Inc. www.FormsWorkflow.com Section B Enter the mailing address where your quarterly tax returns should be sent. Name: Street: City: State: Zip Code: 12. Check the type(s) of motor carrier operations in which you engage. Common Contract Private Exempt 13. Enter your intrastate USDOT Number: Check here if you are applying for a USDOT Number: 14. Check the type(s) of fuel consumed by your Qualified Motor Vehicles: Diesel Gasoline Gasohol Natural Gas Propane Other Request for Decals The decal must be placed on the driver's side door of each Qualified Motor Vehicle operated. Additional decals may be requested during the year. 15. Enter the number of decals needed for your Qualified Motor Vehicles: Applicant agrees, under penalty of perjury, that the information given on this Fuel Tax 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 and mail it, along with this application to: Indiana Department of Revenue Motor Carrier Services Division PO Box 6081 Indianapolis, IN 46206-6081 (317) 615-7345 American LegalNet, Inc. www.FormsWorkflow.com MCFT-1 Instructions R2/2-05 Indiana Department of Revenue Intrastate Motor Carrier Fuel Tax Annual Permit and Application Instructions 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 handbook or forms, go to www.state.in.us/dor/mcs/ forms.html. Please enter all requested information. Section B Address of where you would like your return/renewal mailed. Section A Line 1: Nine-digit federal employer identification number Line 12: Primary type of carrier operations in which you (FEIN). will engage. Line 2: Ten-digit Indiana taxpayer identification number (TID). If you do not have one, one will be assigned to you. Line 13: The Intrastate USDOT Number. If you do not have a USDOT number, one will be assigned to you. Line 3: Name and business address of the sole proprietor, Line 14: Fuel type used in your vehicles. partnership, corporation or other legal entity. Line 4: Indicate whether the business is registered as a Line 15: Total number of decals needed. Requests for additional decals must be made in writing and may nonprofit entity in Indiana. result in an audit of your account. Line 5: Indicate the type of business by checking the Sign and date your return. Enclose your payment of appropriate box. $25.00, made payable to the Indiana Department of Revenue, and mail to: 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. Indiana Department of Revenue Motor Carrier Services Division P.O. Box 6081 Indianapolis, IN 46206-6081 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 Questions? power of attorney must be attached to the renewal You can write to us at the above address, or you may call us at (317) 615-7345 from 8:00 a.m. to 4:30 p.m. Monday application. through Friday. Please have your taxpayer identification number available when you call. Line 9: Telephone number of the contact person. Line 10: Business trade name or DBA name and address. Line 11: Business location phone number. American LegalNet, Inc. www.FormsWorkflow.com