Indiana Department of Revenue MCFT-1A State Form 53994 Intrastate Motor Carrier Fuel Tax Annual Permit Application (8-11) Application Fee $25.00 Please print or type all information Section A Taxpayer Information Legal Entity Name: Indiana Taxpayer ID Number (TID): dba Name (if applicable): Federal Employer ID Number (FEIN): Social Security Number (SSN) Physical, Tax Return & Correspondence Mailing and Credential/Decal Mailing, Address(es): Indiana Physical Business Address: Tax Return and Correspondence Mailing Address (if different than Physical) Credential/Decal Mailing Address (if different than Physical) County: Business Entity Information: □ Sole Owner □ Partnership □ Corporation □ LLC □ Government □ Other __________________________________ Please complete the following information if you selected a Business Entity type of Corporation or LLC 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. If this is entity is registered as an LLC is this a Single Member LLC? □ Yes □ No Owner, Partner, and Corporate Officer Information: Last Name, First Name Title (Owner, Partner, etc) Address SSN (Social Security Numbers are required in accordance with IC 4-1-8-1.) Contact Person Name: _________________________________________________________ Phone Number: __________________________ E-mail Address: __________________________________________________ Fax Number: ____________________________ □ Please check this box if you elect to file online quarterly tax returns and renewals in the future. American LegalNet, Inc. www.FormsWorkFlow.com Section B: Apply for your Intrastate Annual Permit (MCFT) License Number of Qualified Vehicles subject to the Motor Carrier Fuel Tax A Qualified Vehicle is one that travels only in the State of Indiana for the transportation of persons or property having: a. two axles with a gross vehicle weight, or registered weight, in excess of 26,000 pounds; b. three axles or more, regardless of weight; or c. in combination (power unit and trailing unit) with a combined gross vehicle weight, or combined registered weight, in excess of 26,000 pounds. One decal will be sent for each qualified vehicle. Additional decals may be requested for Qualified Motor Vehicles added during the calendar year. Please indicate the types of fuel that is consumed by your Qualified Motor Vehicles. □ Diesel □ Methanol □ Compressed Natural Gas (CN) □ M-85 □ Gasoline □ Gasohol □ A-55 □ Bio-Diesel □ Liquid Natural Gas (LN) □ Propane (LP) Bulk Fuel Storage Does this entity maintain Bulk Fuel Storage tanks in Indiana? □ No □ Yes DOT Authority Information regarding your Qualified Vehicles DOT Number Assigned to this Entity: ________________________________________________________ Please check the box that best describes the DOT Authority status of your Qualified Vehicles □ □ □ Applied For – □ BAS-1 Forms Included with this Application This entity has been granted Intrastate Authority This entity is a Registrant. Please attach a copy of the DOT Authority Lease that this entity is operating under The applicant agrees to comply with the reporting, payment, recordkeeping, and license display requirements as specified in the Indiana Code 6-6-4.1 and Article 13 of the Indiana Administrative Code . The applicant further agrees that Indiana may withhold any refunds due if the applicant is delinquent on any Indiana listed tax due or for payment of fuel taxes due to 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 MCFT 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: Printed Name: Title: Phone Number: Make your check for $25.00 payable to the Indiana Department of Revenue and mail along with this application to: Indiana Department of Revenue Motor Carrier Services Division 5252 Decatur Blvd Suite R Indianapolis, IN 46241 (317) 615-7345 American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department of Revenue Intrastate Motor Carrier Fuel Tax Annual Permit Application Form MCFT-1A What is Motor Carrier Fuel Tax (MCFT)? Motor Carrier Fuel Tax (MCFT) is a tax that is calculated on the fuel purchased and used in a qualified vehicle that travels only in Indiana. Who Must File Individuals and Companies based in Indiana who have qualified vehicles that travel only in Indiana. Are your vehicles qualified vehicles? Your vehicle(s) are qualified vehicles requiring MCFT licensing and reporting intrastate motor carrier activity if: • It has 3 or more axles; or • It has a gross vehicle weight rating or license plate weight greater than 26,000 lbs. by itself; or • When towing a trailing unit such as a trailer, its weight, when added together with the power unit, has a combined gross vehicle weight rating or license plate weight greater than 26,000 lbs. If you travel across state lines and operate a qualified vehicle listed above you will need to complete Form IFTA-1A for Interstate Fuel Tax Agreement (IFTA) License and reporting How to Register for Motor Carrier Fuel Tax (MCFT) You must first complete the application form, MCFT-1A. 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) decal for each qualified vehicle and one (1) MCFT Intrastate license cab card for your company. You will then 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. Each quarter you will be required to submit a Quarterly Fuel Tax return (Form MCFT-101) to calculate your fuel tax due. Failure to submit your return timely may result in penalties, interest, MCFT Intrastate license revocation, and/or assessments. Annually you will need to submit a Renewal Application for the next calendar year compliance decals and MCFT Intrastate license cab card. Failure to renew timely may result in penalties, or revocation fees. If you no longer have a business need for your MCFT Intrastate License or if your operations have changed to include interstate travel please contact our office for instructions on how to close or modify your account. Questions? Visit our web-site at www.in.dor.gov/mcs. If you need further assistance you can email us at Indianamotorfuel@in.dor.gov, or you call us at (317) 615-7345 from 8:15 a.m. to 4:30 p.m. Monday through Friday. Specific Instructions Following you will find specific instructions on how to complete the MCFT-1A, Intrastate Motor Carrier Fuel Tax Application Getting Started To complete Form MCFT-1A, have the following information available: 1. Your federal employer identification number (EIN) 2. Owner, Partner, or Officer social security number(s) (SSN) 3. Your Indiana TID number if already established 4. Your USDOT or INDOT number or if already established MCFT-1A Instructions R1/7-11 American LegalNet, Inc. www.FormsWorkFlow.com MCFT-1A Instructions R1/7-11 Section A: Taxpayer Information Legal Entity Name - Name of the sole proprietor, partnership, corporation or other legal entity. DBA Name (if applicable) - Business trade name or Assumed Name. Indiana Taxpayer ID Number (TID) - Ten-digit Indiana taxpayer identification number (TID). If you do not have an Indiana Taxpayer Identification Number (TID) leave the space blank and one will be assigned to you. Federal Employer ID Number (FEIN) – Nine-digit federal employer identification number (FEIN). Social Security Number (SSN) if applicable – this is necessary for sole proprietor applications if a FEIN is not assigned Physical, Tax Return, & Correspondence Mailing and Credential/Decal Mailing Address(es) – Physical address of the business where records are located including county. Other addresses should be filled out as applicable if different than Physical Address. Business Entity Information - Indicate the type of business by checking the appropriate box. If a Corporation or LLC complete lines A through E. Owner, Partner, and Corporate Officer Information - List each owner, partner, or corporate officer along with SSN. If more space is needed, attach additional sheets. (see IC 4-1-8.1 for additional information) Contact Person - 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 Form POA-1, Power of Attorney, must be attached to the renewal application. Section B: Apply for your Intrastate Annual Permit (MCFT) License Number of Qualified Vehicles subject to the Motor Carrier Fuel Tax - Total number of decals needed. Requests for additional decals can be made in writing, or via phone, and may result in a review of your account. Types of fuel consumed by your Qualified Motor Vehicle - Check the box for all fuel types used in your qualified vehicles. Bulk Fuel Storage – If this entity maintains its own bull fuel storage tanks please provide the requested information. DOT Authority Information regarding your Qualified Vehicles – Check the box which best describes the status of your Intrastate USDOT/Indiana ID Number. (Please attach documents as necessary) If you have questions regarding your Intrastate USDOT/Indiana ID Number please contact (317) 615-7350. Sign and date your application Enclose your payment of $25.00 made payable to the Indiana Department of Revenue and mail to the following address: Motor Carrier Services Division-MCFT Section 5252 Decatur Blvd Ste R Indianapolis, IN 46241-9585 Need a Handbook or information regarding Recordkeeping requirements? Download a copy of the fuel tax handbook or forms at www.in.gov/dor/mcs. You can also get your questions answered via phone at (317) 615-7345 from 8:15 a.m. to 4:30 p.m. Monday through Friday, or email at indianamotorfuel@in.dor.gov American LegalNet, Inc. www.FormsWorkFlow.com