FORM M-233IC State Form 51481 (R6 / 7-11) Section 1 Indiana Department of Revenue Oversize/Overweight Inquiry/Change Form Please check which type of transaction you are requesting.  Cancellation of a requested permit. If your request is received before we issue your permit, the request will be honored. (generally a fee will be charged for the cancellation of a superload permit) (Complete Section 1)  Permit Inquiry (Complete Section 1)  Permit Change for a issued or requested permit (Complete Section 1 and 2) Company Name Contact Telephone Number Permit Number (If Applicable) Fax Number Social Security Number (If Sole Proprietor) Federal Identification Number Original Tractor Serial Number Section 2 Permit change: Please make changes in the appropriate areas below. A Permit can only be changed within 72 hours from the issue date, except for annual and 90 day premits which you are allowed only one (1) tractor change before expiration. Tractor: Enter new tractor Serial Number - $3.00 fee ____________________________________ (this change can only be made if original tractor is inoperable). Make of Tractor ____________________________________ License Plate Number _______________________________ State Where Licensed _______________________________ Year of Tractor _____________________________________ Dimension & Weight: Enter new dimensions or weight - $3.00 fee _________________________ (mobile homes cannot apply for this type of change). Axle weight or spacing changes, please enter below. Axle Weights: 2.____________ 3.___________ 4.___________ 5.____________ 6._____________ 7.____________ 8.___________ 9. ___________ 10.___________ 1._____________ 2.____________ 3.___________ 4.___________ 5.____________ 6._____________ Axle Spacing: 1._____________ 7.____________ 8.___________ 9. ___________ 10.___________ Routes: Enter new route - $3.00 fee ___________________________________________________________________ _______________________________________ (the beginning or the end of a route will not be changed). Time Extension: Only one extension will be granted before a permit expires (extensions vary based upon the type of permit) $6.00 fee. No other provisions on the original permit can be changed. Motor Carrier Service OS/OW Permit Section 5252 Decatur Blvd., Ste. R Indianapolis, IN 46241 Phone: (317) 615-7320 Fax: (317) 821-2336 Under penalties of perjury, I declare I have examined the above information, and to the best of my knowledge and belief it is true, correct and complete. _____________________________________________________ _______________________________ Signature Date American LegalNet, Inc. www.FormsWorkFlow.com