UNIFIED CARRIER REGISTRATION PROGRAM IMPORTANT NOTICE FOR ALL INTERSTATE MOTOR CARRIERS, FREIGHT FORWARDERS, BROKERS & LEASING COMPANIES If you operate a tractor, truck or bus in interstate or international commerce, the registration requirements of the Unified Carrier Registration Agreement (UCR) apply to your business. The Unified Carrier Registration (UCR) requires individuals and companies that operate commercial motor vehicles in interstate or international commerce to register their business with Indiana and pay an annual fee based on the size of their fleet. Motor private carriers of passengers only are not required to register and pay fees under the UCR. The revenues generated will be used for enforcement of motor carrier safety programs. Companies operating solely as brokers, freight forwarders or leasing companies are also required to register and pay a fee of $76. Companies providing both motor carrier services as well as broker, freight forwarder or leasing services are required to pay the fee level set at the motor carrier level. A “commercial motor vehicle” (is defined under 49 USC 31101) means a self-propelled vehicle used on the highways in commerce principally to transport passengers or cargo, if the vehicle: (a) has a gross vehicle weight rating or gross vehicle weight of at least 10,001 pounds, whichever is greater: (b) is designed to transport more than 10 passengers (including the driver); or (c) is used in transporting hazardous materials in a quantity requiring placarding under section 5103. You must register for calendar year 2011 by November 30, 2010 in order to be in compliance by January 1st 2011. NOTE: You must maintain a list of vehicles you have excluded for UCR. This form will be available on www.ucr.in.gov . American LegalNet, Inc. www.FormsWorkFlow.com THE FEE BRACKETS FOR MOTOR CARRIERS, FREIGHT FORWARDERS, BROKERS OR LEASING COMPANIES ARE AS FOLLOWS: Fleet Size Fee per Company ----------------------------------------------------------------------0-2 $ 76.00 3-5 $ 227.00 6 - 20 $ 452.00 21 - 100 $ 1,576.00 101 - 1,000 $ 7,511.00 1,001 - Over $ 73,346.00 Example: A broker also offering services as a motor carrier operating four tractors and nine straight trucks has a fleet size of thirteen commercial motor vehicles and pays $452.00. IMPORTANT NOTICE: If you operated in 2009 and/or 2010 you must pay both your 2009 and/or 2010 UCR fees. To avoid delays it is highly recommended that you register on-line at www.ucr.in.gov and follow the step by step instructions. Payments may be made on-line using MasterCard, Visa or E-Check. Please note, if you pay via credit card you will be charged an access fee based on the total bill. If you pay by E-Check you will incur a $1 fee. If you would like to mail in your application you may go to http://www.in.gov/dor/4195.htm or http://www.ucr.in.gov to print out the BAS-2 form. Make checks payable to the Indiana Department of Revenue. If you would like the form mailed to you contact the Indiana Motor Carrier Services Division at (317) 615-7350. Indiana Department of Revenue Motor Carrier Services Division Insurance and Safety Section P. O. Box 6075 Indianapolis, IN 46206-6075 American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department of Revenue UNIFIED CARRIER REGISTRATION FORM -Year 2011 Motor Carrier Services Division P. O. Box 6075 Indianapolis, IN 46206-6075 To register online go to: www.ucr.in.gov BAS-2 State Form 46139 (R6/ 10-10) SECTION 1. GENERAL INFORMATION USDOT Number MC or MX Number FF Number Telephone Number Legal Name Fax Number E-Mail Address Doing Business Under The Following Name (DBA) Principal Place Of Business Street Address (See Instructions) Principal Business City Principal Business State Zip Code Mailing State Mailing Zip Code Mailing Street Address Mailing City SECTION 2. CLASSIFICATION – Check All That Apply Motor Carrier Motor Private Carrier Broker Leasing Company SECTION 3. FEES DUE-BROKERS, FREIGHT FORWARDERS AND LEASING COMPANIES ONLY Freight Forwarder Note: If your company is also a motor carrier or motor private carrier, skip this section and go to section 4. Brokers, freight forwarders and leasing companies (not combined with a motor carrier entity), please submit the amount due of $76 in the form of payment acceptable by your base state and go to Section 7. SECTION 4. NO. OF MOTOR VEHICLES– MOTOR CARRIER & MOTOR PRIVATE CARRIER Check only one box: The number of vehicles shown below has been taken from section 26 of your last reported MCS-150 form. The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30, 2010. LINE NO. NUMBER OF STRAIGHT TRUCKS AND TRACTORS (COLUMN A) (COLUMN B) NUMBER OF MOTOR COACHES, SCHOOL BUSES, MINI-BUSES, VANS AND LIMOUSINES (COLUMN C) TOTAL (COLUMN D) 1. Subtract:  The number of vehicles on Line 1 in Column C above that has a vehicle capacity of 10 or less passengers, including the driver. 2.  (Optional) The number of vehicles on Line 1 in Column A above that is used only in intrastate ( ) commerce. You are required to maintain a list of vehicles excluded under this option. (Optional) Add a number of vehicles not shown on Line 1 above that are:  Commercial motor vehicles operating solely in intrastate commerce. (See instructions for definition of commercial motor vehicle.) 3.  Used in commerce to transport passengers or property for compensation and have a GVWR or GVW of 10,000 lbs or less, or a passenger capacity of 10 or less, including the driver. 4. Total Number of Vehicles (Line 1 minus Line 2 plus Line 3) SECTION 5. FEE TABLE Number of Number of Vehicles Amount Due Number of Vehicles Amount Due Amount Due Vehicles $76 $452 0-2 6-20 101-1000 $7,511 3-5 $227 21-100 $1,576 1001 or more $73,346 SECTION 6. FEES DUE – MOTOR CARRIER & MOTOR PRIVATE CARRIER Using the number of vehicles in Section 4, Line 4 above, enter the Amount Due from the table above. Note: See last page of this pamphlet for the types of payment your selected base state will accept. $ SECTION 7. CERTIFICATION I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute and file this document on behalf of the applicant. (Penalty provisions subject to the laws of the registration state.) Date Name Of Owner Or Authorized Representative (Printed) Signature Title American LegalNet, Inc. www.FormsWorkFlow.com Instruction Sheet for UCR Carrier Registration What is my base state for UCR? (A) If your principal place of business as completed in Section 1 of the form is AK, AL, AR, CA, CO, CT, DE, GA, IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NM, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, WA, WI or WV, you must use that state as your base state. If your principal place of business is not in one of these states, go to (B). (B) If your principal place of business is not one of the states listed in (A) above but you have an office or operating facility located in one of the states listed in (A) above, you must use that state as your base state. (C) If you cannot select a base state using (A) or (B) above, you must select your base state from (A) above that is nearest to the location of your principal place of business; or (D) Select your base state as follows: a. If your principal place of business is in DC, MD, NJ, or VT or the Canadian Province of ON, NB, NL, NS, PE, or QC, you may select one of the following states: CT, DE, MA, ME, NH, NY, PA, RI, VA, or WV. b. If your principal place of business is in FL or a state of Mexico, you may select one of the following states: AL, AR, GA, KY, LA, MS, NC, OK, SC, TN, or TX. c. If your principal place of business is in the Canadian Province of ON, MB or NU, you may select one of the following states: IA, IL, IN, KS, MI, MN, MO, NE, OH, or WI. d. If your principal place of business is in AZ, HI, NV, OR, or WY or the Canadian Province of AB, BC, MB, NT, NU, SK, or YT or a state of Mexico, you may select one of the following states: AK, CA, CO, ID, MT, ND, NM, SD, UT, or WA. Change of Base State  If you selected your base state using (C) or (D) above and your principal place of business has moved to a qualified state in (A) or (B) above, you may at the next registration year change your base state to a state listed in (A) or (B). Section 1. – General Information  Enter all identifying information for your company. The owner and DBA name should be identical to what is on file for your USDOT number (See http://safer.fmcsa.dot.gov/CompanySnapshot.aspx). Enter the principal place of business address that serves as your headquarters and where your operational records are maintained or can be made available. Section 2. – Classification (Definitions)      “Motor carrier” means a person providing motor vehicle transportation for compensation. “Motor private carrier” means a person who provides interstate transportation of property in order to support its primary line of business. “Broker” means a person, other than a motor carrier, who sells or arranges for transportation by a motor carrier for compensation. “Freight forwarder” means a person who arranges for truck transportation of cargo belonging to others, utilizing for-hire carriers to provide the actual truck transportation, and also performs or provides for assembling, consolidating, break-bulk and distribution of shipments and assumes responsibility for transportation from place of receipt to destination. “Leasing company” means a person or company engaged in the business of leasing or renting for compensation motor vehicles they own without drivers to a motor carrier, motor private carrier, or freight forwarder. Section 3. - Fees Due-Brokers, Freight Forwarders and Leasing Companies  Brokers, freight forwarders and leasing companies pay the lowest fee tier. If your company is also a motor carrier (whether private or for-hire) you will skip this section of the application. Section 4. - No. Of Motor Vehicles– Motor Carrier & Motor Private Carrier       Check the appropriate box indicating where you obtained the vehicle count for the numbers you entered into the table in this section. Line 1. In the table, enter the number of commercial motor vehicles you reported on your last MCS-150 form or the total number of commercial motor vehicles owned and operated for the 12-month period ending June 30 of the year immediately prior to the year for which the UCR registration is made. This table includes owned and leased vehicles (term of lease for more than 30 days). Do not include any trailer counts in Columns A, C or D on this line. Trailers are no longer counted in determining fees under this program. Line 2. Subtract the number of vehicles designed to transport 10 passengers or less, including the driver, that are included in Column C of Line 1. (Optional). You may also subtract the number of property carrying vehicle(s) used solely in intrastate commerce (never used to carry interstate freight) that you included in Section 4, Columns A. You may not enter on this line the number of passenger carrying vehicles included in Column C that were used solely in intrastate commerce. You must maintain a list of vehicles you deleted under this option. Line 3. (Optional). You may add the number of owned commercial motor vehicles (straight trucks, tractors, motor coaches, school buses, minibuses, vans or limousines) that were used only in intrastate commerce if they were not included in Column A or C above. You may also include on this line the number of other self propelled vehicles used in interstate or intrastate commerce to transport passengers or property for compensation that are not defined as a commercial motor vehicle that have a gross vehicle weight rating or gross vehicle weight of 10,000 lbs or less or a passenger capacity of 10 or less, including the driver. Line 4, Total Number of Vehicles. Total the number of vehicles shown in Column D. Use this total and go to the fee table in Section 5. Pay the amount due for your total number of vehicles. Definition - “Commercial motor vehicle” (as defined under 49 USC Section 31101) means a self-propelled vehicle used on the highways in commerce principally to transport passengers or cargo, if the vehicle: (1) Has a gross vehicle weight rating or gross vehicle weight of at least 10,001 pounds, whichever is greater; (2) Is designed to transport more than 10 passengers, including the driver; or (3) Is used in transporting material found by the Secretary of Transportation to be hazardous under section 5103 of this title and transported in a quantity requiring placarding under regulations prescribed by the Secretary under section 5103.” Section 5. – Fee Table for Motor Carrier & Motor Private Carrier  This table is the approved UCR fees you will pay dependent upon the number of vehicles reported in Section 4. This fee may change from year to year. Contact your base state if you do not have the fee table for the correct registration period. Section 6. – Fee Due for Motor Carrier & Motor Private Carrier  Enter the amount due for the total number of vehicles calculated in Section 4. Section 7. – Certification  The owner or an individual who has a power of attorney to sign on behalf of the owner or owners must sign this form. This certification indicates that the information is correct under penalty of perjury. American LegalNet, Inc. www.FormsWorkFlow.com