Credit Card Payment Authorization Form For Motor Carrier Services Division {MC-CCP}

State Form 51694 (R4 / 12-15) MC-CCP Indiana Department of Revenue Credit Card Payment Authorization Form For Motor Carrier Services Division Use this form anytime you want to use a credit card to pay a Motor Carrier Services Division fee or billing. Fax this Authorization form in with your Motor Carrier Services form or billing (i.e., BAS-2, IFTA-101, etc.) to the applicable fax number, which can be found on the instructions for Credit Card Payment. Please note: If you are faxing in a form or billing and/or payments to more than one section, you must fax the applications and credit card sheets to each individual section. You cannot combine payment types. Legal Name: ____________________________________________________________________________________ DBA Name: _____________________________________________________________________________________ Name on Credit Card: _____________________________________________________________________________ Address: ___________________________ City: _________________ State: _____ Zip Code: ____________ Telephone Number: _______________________________________________________________________________ DOT Number: ____________________________________ TID Number: _____________________________________ IRP Account Number: _________________ FHWA/MC Number: ___________________________ FEIN/SSN: __________________________________ Fleet Number: __________________________ Reg. Year: __________________________________ Transaction Numbers: _____________________________ MasterCard Month Year Visa Put on file: Account Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date: ____/_____ Amount: $____________ One Time Use: Cardholder Signature: ________________________________ Email: _______________________________ I agree to the credit card processing fee calculated at $1 plus 2% of the total owed. American LegalNet, Inc. www.FormsWorkFlow.com for Motor Carrier Services Division Note: This form is used if you choose to pay your fees using your Visa or Mastercard. Legal Name: If you are a sole proprietor this will be your name. If you are a partnership enter the legal partnership name. If you are a corporation enter the corporation name. DBA Name: If your business entity is operating under a name other than your legal name, enter that name here. Otherwise enter "N/A" if this does not apply. Name on Credit Card: Enter the name that appears on the credit card. Address: Enter the complete mailing address of the credit card. Telephone Number: Enter the telephone number, including the area code, of the principal place of business. DOT Number: Enter your US DOT number or Indiana ID number assigned to your motor carrier operation by either the U.S. Department of Transportation or the Indiana Department of Revenue. Otherwise enter "N/A" if your are a new applicant. FHWA/MC Number: Enter the motor carrier "FHWA" or "MC" number under which the Federal Highway Administration (FHWA) issued your operating authority, if applicable. Otherwise enter "N/A" if this does not apply. Taxpayer Identification Number: This is the Taxpayer Identification Number issued by the Indiana Department of Revenue. Otherwise enter "N/A" if you are a new applicant. FEIN/SSN: This is the Federal Employer Identification Number for corporations, partnerships, and LLC's. Enter your social security number if you are a sole proprietor. International Registration Plan Number: This is your IRP (International Registration Plan) number issued by the Indiana Department of Revenue. Otherwise enter "N/A" if you are a new applicant or this does not apply. Fleet Number: This is the fleet number for your IRP account number. Otherwise enter "N/A" if you are a new applicant or this does not apply. Transaction Number: This is your transaction number for your IRP renewal. This can be found on your preprinted IRP renewal. Otherwise enter "N/A" if you are a new applicant or this does not apply. Reg. Year: This is the calendar year that you are remitting fees. Otherwise enter "N/A" if you are a new applicant or this does not apply. Master Card or Visa: Mark the box that applies for the type of charge card you are using. Account Number: This is your account number for the credit card you are using. Expiration Date: Enter the expiration date for the credit card that you are using. Amount: Enter the amount that you are authorizing the Department of Revenue to charge for a transaction with the understanding additional credit card fees may apply on your card. Put on file: Check this option to put card on file to use for future payments. One Time Use: This option only gives permission to use this credit card for this transaction only with the understanding additional credit fees may apply on your card. Credit Card Holders Signature: The person that the credit card belongs to must sign the form in order to authorize the Department to charge fees to that account. Email: Enter your email address. To expedite your service, please be sure to fax your paperwork along with the credit card authorization form to the correct section. The fax numbers per section are listed below. UCR Fax Numbers US DOT & UCR (317) 615-7374 MCFT & IFTA (317) 615-7333 IRP (317) 615-7280 OS/OW (317) 615-7241 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for MC-CCP, Credit Card Payment Authorization Form