International Fuel Tax Agreement Application {IFTA-1A}

Form IFTA-1A State Form 54049 (R2 / 3-13) International Fuel Tax Agreement Application Application Fee $25 Please print or type all information Indiana Department of Revenue Section A: Taxpayer Information 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? Yes No SSN (Social Security Owner, Partner, and Corporate Officer Information: Last Name, First Name Title (Owner, Partner, etc.) Address numbers are required in accordance with IC 4-1-8-1.) Contact Person: Name: _____________________________________ Telephone Number: _________________________ Fax Number: ___________________________ Email Address: _____________________________________ Please check this box if you elect to file online quarterly returns and renewals in the future. (Requires a valid email account.) American LegalNet, Inc. www.FormsWorkFlow.com Section B: Application for Your International Fuel Tax (IFTA) License 1. Number of qualified vehicles subject to the Indiana Motor Carrier Fuel Tax ­ IFTA A qualified vehicle is one that travels in two or more jurisdictions 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 set of decals will be sent for each qualified vehicle. Additional decals may be requested for qualified motor vehicles added during the calendar year. Diesel (DI) Methanol (MH) Compressed Natural Gas (CN) M-85 (M8) 2. Please indicate the type(s) of fuel consumed by your qualified motor vehicles Gasoline (GA) Gasohol (GH) A-55 (A5) Bio-Diesel (BD) Liquid Natural Gas (LN) Propane (LP) All U.S. Jurisdictions Alabama (AL) Illinois (IL) Arizona (AZ) Indiana (IN) Arkansas (AR) Iowa (IA) California (CA) Kansas (KS) Colorado (CO) Kentucky (KY) Connecticut (CT) Louisiana (LA) Delaware (DE) Maine (ME) Florida (FL) Maryland (MD) Georgia (GA) Massachusetts (MA) Idaho (ID) Michigan (MI) All Canadian Jurisdictions Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland & Labrador (NL) Nova Scotia (NS) No Yes No Yes 3. Select the jurisdictions where operation of qualified motor vehicles may occur Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virgin Islands (VI) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) NW Territory (NT) Ontario (ON) Prince Edward Island (PE) Quebec (QC) Saskatchewan (SK) Yukon Territories (YT) 4. Previous IFTA licenses issued Has this entity ever been issued an IFTA license before? List each jurisdiction that has previously issued an IFTA license to this entity: __________ _________ __________ __________ __________ __________ _________ Has an IFTA license issued to this entity ever been suspended or revoked? List each jurisdiction in which your IFTA license was suspended or revoked: __________ _________ __________ __________ __________ __________ _________ American LegalNet, Inc. www.FormsWorkFlow.com Section B: Application for Your International Fuel Tax (IFTA) License (Continued) 5. Bulk fuel storage Does this entity maintain bulk fuel storage tanks? No Yes List each jurisdiction in which you maintain bulk fuel storage tanks: __________ _________ __________ __________ __________ __________ _________ 6. International Registration Plan (IRP) information regarding your qualified vehicles Indiana IRP Account Number Assigned to this Entity If no Indiana IRP account is assigned to this entity, please check the box that best describes the registration status of your qualified vehicles. ______________________________________________________ Applied for Forms included with this application All qualified vehicles are leased on to a carrier that provides IRP plates - Please provide their IRP state and account number _____________________(a copy of this lease agreement may be requested for verification purposes). All qualified vehicles have specialized Indiana base plates Farm Transporter Municipal Dealer Please attach copies of Indiana registration for each subject vehicle. All qualified vehicles are operated under an owner/operator agreement - Please attach a sample of standard owner/operator lease issued to independent contractors for this entity with an estimate of the number of leases to be issued in this credential year. 7. DOT authority information regarding your qualified vehicles U.S. DOT number assigned to this entity Please check the box that best describes the DOT authority status of your qualified vehicles ________________________________________________ Applied for Forms included with this application This entity has been granted Interstate Authority. Please provide MC/FHWA number _______________________ This entity is registered as a private carrier and/or exempt commodity for-hire carrier, which is exempt from Interstate authority requirements. 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 International Fuel Tax Agreement. 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