Indiana Department of Revenue Proportional Use Credit Certification Application Fee $7.00 PROP-1 Rev. 08/00 Complete this Section only if different than lines 1, 3, 5, 6, 7. 1. Legal Name 2. Doing Business As (DBA) 3. Physical Address 4. Mailing Address 5. City 6. State/Province 11. County 12. Telephone Number ( 7. Zip Code 8. City 9. State/Province 10. Zip Code 13. Federal Identification Number 14. Social Security Number 18. Base State/Jurisdiction ) 15. Interstate U.S. DOT Number 16. Indiana IFTA Number 17. IFTA Number (If Non-IN. IFTA) 19. Indiana U.S. DOT Number 20. Indiana Motor Carrier Number 21. E-Mail Address NOTE: If you ARE NOT an Indiana IFTA/Motor Carrier Account and are registered in another jurisdiction, proceed to line 22. All others go to line 24. 22. Check the type of organization of this business: Sole Proprietorship Partnership Corporation Government Other ______________ 23. Non-Indiana Based Corporation must provide the following information: State of Incorporation: Date of Incorporation: Enter the date authorized to do business: State of Commercial Domicile: Accounting period year ending date (MM/DD): Non-Indiana Based Corporation - List Name of Owner, Partners or Officers (Attach additional sheets) Last Name, First, Middle Initial Title Street Address City State Zip Social Security Number I do hereby certify under penalty of perjury that the foregoing and attached information is a true and correct statement to the best of my knowledge and is a complete and full representation based upon the best information available. 24. Signature of Taxpayer/Authorized Agent Typed or Printed Name Title - Date Signed Telephone Number ( ) This application MUST be signed by the owner, general partner or corporate officer before it will be processed by the Department. For more information regarding this application, you may contact the Department at (317) 615-7345. Mail completed application, all relevant documentation and application fees to: Indiana Department of Revenue Motor Carrier Services Division P.O. Box 6078 Indianapolis, IN 46241-6078 American LegalNet, Inc. www.FormsWorkflow.com Vehicle Information (This section must be completed by all applicants) If you have more than 5 vehicles, please attach printout Vehicle Code Vehicle Identification Number Power Units Only Vehicle Type TK or TR Vehicle Make List of Eligible Vehicles Line By Line Instructions CODE Line 1: Enter Legal Name or Sole Proprietorship, Partnership, Corporation, or other legal name. Lines 3, 5, 6, 7 & 11: Enter the actual location of your business by providing the Street Address, City, State/Province, Zip Code and County* (*Indiana businesses only). Lines 2,4,8,9,10: Enter the appropriate information ONLY if different than lines 1,3,5,6,7,11. Line 12: Enter the area code and telephone number of your principle place of business. Line 13: Enter your nine (9) digit Federal Identification Number. Line 14: Enter your Social Security Number if your business does not have a Federal Identification Number. Line 15: Enter your INTERSTATE US DOT Number (you will have an Interstate US DOT Number if your vehicle(s) operate outside the state of Indiana.) Line 16: Enter your Indiana IFTA Tax Identification Number (if based in Indiana.) Line 17: Enter your IFTA Account Number if based outside the state of Indiana. Line 18: Enter your Base State/Jurisdiction in which you have your IFTA registered. Line 19: Enter your Indiana US DOT Number (you will have an IN US DOT Number if your vehicle(s) operate in the state of Indiana only). Line 20: Enter your Indiana Motor Carrier Account Number. Line 21: Enter an e-mail address to send/receive correspondence to/from the Department. Line 22: To be entered by NON-INDIANA CARRIERS ONLY. Check the appropriate business type here. If a CORPORATION, complete Line 23. All others go to Line 24. Line 23: Enter the requested information below. This certificate will not be processed without this section completed. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Air Conditioning Unit for Buses ...................................... Bookmobile ..................................................................... Boom Trucks-Block Boom .............................................. Bulk Feed Trucks ............................................................ Car Carrier with Hydraulic Winch ................................... Carpet Cleaning Van ...................................................... Cement Mixers ................................................................ Distribution Truck-Hot Asphalt ........................................ Dump Trailers ................................................................. Dump Trucks .................................................................. Fire Truck ........................................................................ Leaf Truck ....................................................................... Lime Spreader ................................................................ Line Truck-Digger/Derrick, Aerial Lift Truck .................... Milk Tank Trucks ............................................................. Mobile Cranes ................................................................ Pneumatic Tank Truck .................................................... Refrigeration Truck ......................................................... Salt Spreader-Dump with Spreader ................................ Sanitation Dump Trailers ............................................... Sanitation Truck .............................................................. Seeder Truck .................................................................. Semi Wrecker ................................................................. Service Truck with Jackhammer, Pneumatic Drill .......... Sewer Cleaning Truck Sewer Jet, Sewer Vactor ............ Snow Plow ...................................................................... Spray Truck .................................................................... Super Sucker .................................................................. Sweeper Truck ................................................................ Tank Trucks .................................................................... Tank Transport ................................................................ Truck with Power Take Off Hydraulic Winch ................... Wrecker .......................................................................... 10% 35% 20% 15% 10% 15% 30% 10% 15% 23% 48% 20% 15% 20% 30% 42% 15% 15% 15% 15% 41% 15% 35% 15% 35% 10% 15% 90% 20% 24% 15% 20% 10% Please use the code number when listing the vehicles on this Certification and all Claims for Credit forms. Also use these codes when adding/deleting vehicles quarterly. Line 24: Enter the signature of Taxpayer/Authorized Agent. ****IMPORTANT**** A carrier must complete this application and be certified by the department in order to qualify for a proportional use credit. A carrier must apply to the Department for certification before April 1 of the first calendar year for which the proportional use will be claimed. NOTE: Once the carrier has been certified by the Department, that certification is valid for all subsequent calendar years. American LegalNet, Inc. www.FormsWorkflow.com