Intrastate Motor Carrier Fuel Tax Annual Permit Application {MCFT-1A}

MCFT-1A State Form 53994 (R2 / 3-13) Intrastate Motor Carrier Fuel Tax Annual Permit Application Application Fee $25 Please print or type all information Section A Taxpayer Information Indiana Department of Revenue Legal Entity Name Indiana Taxpayer ID Number (TID) Federal Employer ID Number (FEIN) Social Security Number (SSN) DBA Name (if applicable) Address(es): Indiana Physical Business Address Tax Return and Correspondence Mailing Address (if different from Physical) Credential/Decal Mailing Address (if different from Physical) County Business Entity Information: Sole Owner Partnership Corporation LLC Government Other __________________________________ Please complete the following information if you selected a Business Entity type of Corporation or LLC A. State of incorporation B. Date of incorporation C. State of commercial domicile D. If not incorporated in Indiana, enter the date authorized to do business in Indiana E. If this entity is registered as an LLC, is this a Single-Member LLC? Owner, Partner, and Corporate Officer Information: SSN (Social Security Last Name, First Name Title (Owner, Partner, etc.) Address numbers are required in accordance with IC 4-1-8-1.) Yes No Contact Person: Name: _________________________________________________________ Email Address: __________________________________________________ Telephone Number: _______________________ Fax Number: ____________________________ Please check this box if you elect to file online quarterly tax returns and renewals in the future. American LegalNet, Inc. www.FormsWorkFlow.com Section B: Application for Your Intrastate Annual Permit (MCFT) License Number of Qualified Vehicles subject to the Motor Carrier Fuel Tax A Qualified vehicle is one that travels only in the State of Indiana for the transportation of persons or property having: a. two axles with a gross vehicle weight or registered weight in excess of 26,000 pounds; b. three axles or more, regardless of weight; or c. in combination (power unit and trailing unit) with a combined gross vehicle weight or combined registered weight in excess of 26,000 pounds. One decal will be sent for each qualified vehicle. Additional decals may be requested for qualified motor vehicles added during the calendar year. Please indicate the type(s) of fuel consumed by your qualified motor vehicles Diesel Methanol Compressed Natural Gas (CN) M-85 Gasoline Gasohol A-55 Bio-Diesel Liquid Natural Gas (LN) Propane (LP) Bulk fuel storage Does this entity maintain bulk fuel storage tanks in Indiana? No Yes DOT authority information regarding your qualified vehicles DOT number assigned to this entity Please check the box that best describes the DOT authority status of your qualified vehicles. ________________________________________________________ Applied for ­ BAS-1 Forms included with this application This entity has been granted intrastate authority. This entity is a registrant. Please attach a copy of the DOT authority lease under which this entity is operating. The applicant agrees to comply with the reporting, payment, recordkeeping, and license display requirements as specified in the Indiana Code 6-6-4.1 and Article 13 of the Indiana Administrative Code. The applicant further agrees that Indiana may withhold any refunds due if the applicant is delinquent on any Indiana listed tax due or for payment of fuel taxes due to any member jurisdiction. Failure to comply with these provisions shall be grounds for revocation of the license in all member states. Applicant agrees, under penalty of perjury, that the information given on this MCFT application is, to the best of their knowledge, true, accurate, and complete. NOTE: This form must be signed by an owner, a partner, or a corporate officer listed on the front of this application or by an authorized agent. If signed by an authorized agent, a properly completed power of attorney must be enclosed with this application. Date Signature Title Printed Name Telephone Number Make your check for $25, payable to the Indiana Department of Revenue, and mail along with this application to: Indiana Department of Revenue Motor Carrier Services Division 7811 Milhouse Road, Suite M Indianapolis, IN 46241-9612 (317) 615-7345 American LegalNet, Inc. www.FormsWorkFlow.com Annual Permit Application Instructions for Form MCFT-1A What Is Motor Carrier Fuel Tax (MCFT)? Motor Carrier Fuel Tax (MCFT) is a tax that is calculated on the fuel purchased and used in a qualified vehicle that travels only in Indiana. Each quarter you will be required to submit a Quarterly Fuel Tax return (Form MCFT-101) to calculate your fuel tax due. Failure to submit your return timely may result in penalties, interest, MCFT intrastate license revocation, and/or assessments. Annually you will need to submit a Renewal Application for the next-calendar year compliance decals and MCFT intrastate license cab card. Failure to renew timely may result in penalties or revocation fees. If you no longer have a business need for your MCFT intrastate license or if your operations have changed to include interstate travel, please contact our office for instructions on how to close or modify your account. Who Must File? Individuals and Companies based in Indiana who have qualified vehicles that travel only in Indiana. Are Your Vehicles Qualified Vehicles? Your vehicle is a qualified vehicle requiring MCFT licensing and reporting intrastate motor carrier activity if: · · · It has three or more axles; or It has a gross vehicle weight rating or license plate weight greater than 26,000 lbs. by itself; or When towing a trailing unit such as a trailer, its weight, when added together with the power unit, has a combined gross vehicle weight rating or license plate weight greater than 26,000 lbs. Questions? Visit our website at www.in.dor.gov/mcs. If you need further assistance you can email us at Indianamotorfuel@dor.in.gov, or call us at (317) 615-7345 from 8:15 a.m. to 4:30 p.m. Monday through Friday. Specific Instructions If you travel across state lines and operate a qualified vehicle listed above, you will need to complete Form IFTA-1A for Interstate Fuel Tax Agreement (IFTA) License and reporting. Following you will find specific instructions on how to complete the MCFT-1A, Intrastate Motor Carrier Fuel Tax Application. Getting Started How to Register for Motor Carrier Fuel Tax To complete Form MCFT-1A, have the following information available: 1. 2. 3. 4. Your federal employer identi