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Joint Application For Sale And Transfer Of Permanent Authority To Transport Passenger Or Household Goods Form. This is a Indiana form and can be use in Department Of Revenue Statewide.
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Tags: Joint Application For Sale And Transfer Of Permanent Authority To Transport Passenger Or Household Goods, 707, Indiana Statewide, Department Of Revenue
Indiana ID/USDOT Number
Form 707
To be completed by Department.
State Form 50219
(R3 / 6-06)
Joint Application for Sale and Transfer of Permanent Authority
To Transport Passenger or Household Goods
Joint application for sale and transfer of ___________________ by
(Certificate or Permit Number)
the Indiana Department of Revenue.
1.
Purchaser Information
a.
Purchaser’s Name (include DBA, if applicable) ___________________________________________________
_____________________________________________________________________________________
b.
Street Address ______________________________________________________________________
c.
City, State, Zip _____________________________________________________________________
d.
Telephone ______________________
e.
Principal place of business in Indiana (if other than above):
County ______________________
_____________________________________________________________________________________
(Street Address)
(City)
(Zip)
(State)
______________________
(County)
f.
Check One: Partnership _____ Corporation _____ Individual _____ Other _____
g.
If purchaser is a partnership, give the name and address of each member thereof; if purchaser is a
corporation, give the name, title, and address of each principal officer.
Name
Address
Name
Address
Name
Address
h. If purchaser is a corporation, LP or LLC, provide the State and the date of incorporation.
_____________________________________________________________________________________
(State)
(Date of Incorporation)
(Total Number of Shares Outstanding)
Last year annual report was filed with Indiana Secretary of State _____________________
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i.
List the name of each shareholder and the number of shares held by each shareholder:
N ame
j.
N umber of S hares
List all other motor carrier companies which hold Indiana Intrastate Authority in which each
shareholder has an interest. Provide the Indiana intrastate certificate or permit numbers held by these
companies.
Motor C arrier C ompany
k.
C ertificate or P ermit N o.
If currently operating under an Indiana certificate or permit, provide the number:
Certificate Number _________________________ Permit Number _________________________
2.
Seller Information
a.
Seller’s Name (include DBA, if applicable)
__________________________________________________________________________________
_____________________________________________________________________________________
b.
Street Address ______________________________________________________________________
c.
City, State, Zip _____________________________________________________________________
d.
Telephone _________________________
e.
Principal place of business in Indiana (if other than above):
County _________________________
_____________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip)
_________________________
(County)
f.
Check One: Partnership _____ Corporation _____ Individual _____ Other
g.
If seller is a partnership, give the name and address of each member thereof; if seller is a corporation,
give the name, title, and address of each principal officer:
Name ____________________
Address ___________________________________________________
Name ____________________
Address ___________________________________________________
Name ____________________
Address ___________________________________________________
Form 707
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h. If seller is a corporation, provide the State and the date of incorporation.
_____________________________________________________________________________________
(State)
(Date of Incorporation)
Last year annual report was filed with Indiana Secretary of State: _________________________________
i.
List all Indiana intrastate authority certificate or permit numbers which the seller will be retaining.
(Attach Copies)
__________________________________________________________________________________________________________________
j.
Is the seller currently in bankruptcy?
Yes
No
If yes, indicate cause number, date of filing and in what court filed: ________________________________
_____________________________________________________________________________________________________________
k.
Has any shareholder, partner or owner of seller ever been a shareholder, partner or owner of a motor
carrier which has filed bankruptcy?
Yes
No If yes, complete the following:
N ame of Shareholder,
Name of Shareholder,
Partner, orr Owner r
Partner o Ow ne
Motorr Carrierr
Moto C arrie
D ate of f
Date o
B ankruptcyPetitionn
Bankruptcy Petitio
C au Number of
Cause se N o. of
B ankruptcy Petitionn
Bankruptcy Petitio
C our
Court t
filed in
Filed In
Did this motor carrier hold Indiana intrastate authority?
Yes
No If yes, what happened to the
certificate or permit as a result of the bankruptcy? ________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
l.
Has the seller performed continuous and adequate service under the certificate or permit now pending
sale and transfer? ___________________________________________________________________
In support of this application, the purchaser submits the following exhibits, attached hereto and made part
hereof:
Exhibit A
Exhibit B
Exhibit C
Exhibit D
Form 707
- A statement describing purchaser’s financial status, including a brief statement of assets and
liabilities as of the date of application, and a copy of applicant’s most recent balance sheet and
income statement.
- A certificate from the Secretary of State of Indiana showing purchaser is registered to do
business in Indiana (if the purchaser is a non-resident corporation); or
A certificate of existence from the Secretary of State of Indiana (if the purchaser is an Indiana
corporation).
- A copy of the certificate or permit being transferred including the scope of authority granted by
the Department.
- If seller is currently in bankruptcy, a copy of the bankruptcy petition.
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WHEREFORE, the joint applicants ask that the Indiana Department of Revenue approve the sale and transfer of
____________________ number ____________________ and issue a _________________________________
(Certificate or Permit)
(Certificate or Permit)
to the purchaser authorizing the operation of motor vehicles as a _____________________ carrier over the
(Common or Contract)
public highways of the State of Indiana upon the route and between the points and serving the cities and towns
as authorized by the above numbered ____________________.
(Certificate or Permit)
_________________________________________
_________________________________________
(Signature of Attorney or Representative or Purchaser)
(Signature of Purchaser)
_________________________________________
_________________________________________
(Print Name of Attorney or Representative)
(Print Name of Purchaser)
_________________________________________
(Address)
_________________________________________
(Telephone Number)
STATE OF ______________ )
) SS:
COUNTY OF ____________ )
Before me the undersigned, a Notary Public for _______________ County, State of Indiana, personally appeared ________________,
and he being first duly sworn by me upon his oath, says that the facts alleged in the forgoing instrument are true. Signed and sealed this
_____ day of ____________________, 20 _____.
______________________________________________
(Signature) Notary Public
______________________________________________
(Printed Name)
County of Residence: ___________________________
My Commission Expires: _____________________________________
____________________________________
______________________________________________
(Signature of Attorney or Representative of Seller)
(Signature of Seller)
____________________________________
______________________________________________
(Print Name of Attorney or Representative)
(Print Name of Seller)
____________________________________
(Address)
____________________________________
(Telephone Number)
STATE OF ______________ )
) SS:
COUNTY OF ____________ )
Before me the undersigned, a Notary Public for _______________ County, State of Indiana, personally appeared ________________,
and he being first duly sworn by me upon his oath, says that the facts alleged in the forgoing instrument are true. Signed and sealed this
_____ day of ____________________, 20 _____.
____________________________________________________
(Signature) Notary Public
____________________________________________________
(Printed Name)
County of Residence: ___________________________
Form 707
My Commission Expires: _____________________________________
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Instructions for Joint Application of Sale and Transfer of Certificate or Permit
Please read these instructions carefully before completing the application.
The application for sale and transfer of a certificate or permit must be typewritten or legible. The original and one copy of
the application must be filed.
45 IAC 16-1.5-3 Any person may appear and represent his or her own interest before the commission. The interest of
another person or entity shall be represented only by an attorney authorized to practice before the commission, pursuant to
this section..
Each line of the application must be completed. If a line is not applicable to you or your company, you should enter
“N/A” in the space provided for the answer.
In order for the application to be processed by the Department, you must include the following with your application:
1.
A filing fee of $100.00; make checks payable to the Indiana Department of Revenue;
2.
A publication fee of $80.00.
Before a certificate or permit will be issued by the Department, I.C. 8-2.1-22-15 requires that a public hearing be held at
which you will be required to show the responsibility of the person obtaining or seeking to obtain ownership or control of
any certificate or permit or part thereof; his readiness, ability, and willingness to perform the service proposed; and whether
the proposed service, to the extent authorized by the certificate or permit, is or will be consistent with the public interest and
the state transportation policy declared by law.
If no protests are filed to your application, the hearing will be summary in nature pursuant to 45 IAC 16-1.5-12(c).
If you have any questions regarding this application, please contact the Department at:
Indiana Department of Revenue
Motor Carrier Services
Insurance and Safety Unit
5252 Decatur Blvd., Ste. R
Indianapolis, Indiana 46241
or call (317) 615-7295
Form 707
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