Indiana Department of Revenue FORM M-233 Oversize/Overweight Vehicle Permit Application State Form 1948 (R7 / 7-11) Section A - Company Information 1. Company Name 2. Trip Start Date 3. FEIN 4. Business Telephone Number 5. Fax Number Section B - Vehicle Information 1. VIN 2. Make of Tractor 4. State Licensed 3. License Plate Number 5. Year of Tractor 7. Vehicle Description (check all that apply)  Tractor-Trailer  Truck-Trailer  Truck  Auto/Traileer 6. Load Serial Number  Self-Propelled Equipment  Other/Towed  Fifth Wheel Hook-Up  Rear Steerable Axle Vehicle Dimensions: 8. Overall Length: ___________ 9. Width: ___________ 10. Height: __________ 11. Total Gross Weight: ______________ 12. Trailer and Load Length___________________ 13. Loaded Axle Weights: d __________ e __________ g __________ h __________ i __________ j __________ b __________ c __________ d __________ e __________ f __________ g __________ h __________ i __________ j __________ a __________ b __________ c __________ d __________ e __________ f __________ 16. Tires per Axle: c __________ a __________ 15. Tire Size: b __________ f __________ 14. Axle Spacing: a __________ g __________ h __________ i __________ j __________ a ______ b ______ c ______ d ______ e ______ f ______ g ______ h ______ i ______ j ______ 17. Width Between Tires: a ______ b______ c______ d______ e______ f ______ g ______ h ______ i ______ j _____ Section C - Permit Information 1. Type of Permit: (Check One)  Oversize - 90-Day Trip  Oversize - Annual  Oversize and/or Overweight Permit  12’ Wide Mobile Home Quarterly  12’ Wide Mobile Home Annual  14’ Wide Mobile Home Quarterly 2. Mileage _________________________ 14’ Wide Mobile Home Annual  Mobile Home Permit Single Trip  US Custom Sealed Ocean Container-Annual 3. Origin ____________________________ 4. Destination__________________ 5. Route to be traveled _____________________________________________________________________________________ _____________________________________________________________________________________ A permit will not be granted if your load is divisible, either by method of loading or disassembly. 6. Describe the load that you are moving: ___________________________________________________________________ 7. (Check One If Applicable) Stacked Side by Side End to End Nested Single This permit does not apply to any state roads or bridges that are closed for construction purposes, or to any roads or bridges that are posted for gross load limits, and/or any roads, structures, wires, etc., having a restricted height and/or width clearance that will not clear said load. This permit does not apply to any county roads or city streets. Section D - Signature Information The General provisions and any Special Provisions are incorporated by reference into this permit and are as binding upon the permit holder as if they had appeared on the face of this permit. This permit is void if the General or Special Provisions are omitted or are not attached. The Indiana Department of Revenue disclaims any responsibility in relation to the correctness in the transmitting of the permit as a whole, or any part thereof, including General or Special Provisions. This Permit is not valid unless signed below by both an authorized company owner or officer, and the driver(s). The driver’s signature attests to the fact that the description of the vehicle and load is accurate and that the General Provisions and any Special Provisions have been read and understood by the driver. Under the penalty of perjury, I have examined this permit, and to the best of my knowledge and belief, it is true, complete and correct. I also understand that all provisions of the Transporting Company Agreement apply in full force. Driver’s Signature Date Driver’s Signature Date Driver’s Signature Date Company Owner or Responsible Officer Signature Date American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department of Revenue Instructions for completing Form M-233 Section A All fields are required to request a permit except Line 15, 16 and 17 which are only required if load exceeds 200,000 pounds total gross weight. Line 1: Line 2: Line 3: Line 4: Line 5: Enter the name of the company Enter the date the permit will begin Enter the company’s Federal Identification Number (FEIN) Enter the telephone number of the business location Enter the company’s fax number Section B Line 1: Enter the VIN number of the vehicle that will be transporting the load Line 2: Enter the make of the vehicle transporting the load Line 3: Enter the license plate number of the transporting vehicle (except if self propelled) Line 4: Enter the state the transporting vehicle is registered in Line 5: Enter the year of the tractor Line 6: You must enter a load serial number here (only if mobile home) Line 7: Check the type of vehicle that will be transporting the load Line 8: Enter the overall length of the vehicle and load Line 9: Enter the width from the widest point of the loaded vehicle Line 10: Enter the height from the tallest point of the loaded vehicle Line 11: Enter the total gross weight of the loaded vehicle Line 12: If the transporting vehicle is a combination vehicle enter the load and trailer length here Line 13: Enter the loaded axle weights, each line represents an axle. Line 14: Enter the axle spacings between each axle *Line 15: Enter the tire size of each axle (only if load exceeds 200,000 pounds) *Line 16: Enter the number of tires per axle (only if load exceeds 200,000 pounds) *Line 17: Enter the width between tires (only if load exceeds 200,000 pounds) Section C Line 1: Line 2: Line 3: Line 4: Check the type of permit that is being requested, check only one. Enter the total miles traveled on Indiana roads. Do not count miles on Toll Road. Enter the Origin which must be a city within Indiana or the state line in which you will be entering from Enter the Destination which must be a city within Indiana or the state line in which you will be exiting to. Line 5: Enter the route to be traveled. If using county roads or city streets please list these in your routes as CR or CS. If using I465, or I469 you must give direction of travel and exit number getting off. If you are over legal height and traveling I465 you must specify you will be using the middle lane on I465. If using the toll road you must give the gate number you will be entering the toll road on and the gate number you will be exiting off of the toll road. Line 6: Enter a description of the load you are transporting. Line 7: Check how the load is being transported. Check only one. Section D All drivers who will be transporting the load must sign the permit before load departure. Company owner or officer must sign the permit before load departure. American LegalNet, Inc. www.FormsWorkFlow.com