Joint Application For Emergency Or Temporary Authority To Transport Passenger Or Household Goods {711}

State Form 50226 (R5 / 3-16) Form 711 IndianaID/USDOTNumber _________________________ (Tobecompletedbythedepartment) Joint Application for Emergency or Temporary Authority To Transport Passenger or Household Goods Joint application of the Indiana Department of Revenue for _____________________________ (Emergency Temporary or Temporary) authority pending the sale and transfer of ______________________________. (CertificateorPermitNumber) 1. Purchaser Information a. Purchaser'sName(includeDBA,ifapplicable) ________________________________________________________________________________________ b. StreetAddress ____________________________________________________________________________ c. City,State,ZipCode ________________________________________________________________________ d. TelephoneNumber ________________ County _____________ EmailAddress _______________________ e. PrincipalPlaceofBusinessinIndiana(ifotherthanabove): ________________________________________________________________________________________ (StreetAddress) (City) (State) (ZipCode) _______________________________ (County) f. CheckOne:Partnership _______ Corporation _______ Individual _______ Other _______ g. Ifpurchaserisapartnership,givethenameandaddressofeachmemberthereof;ifpurchaserisacorporation, givethename,title,andaddressofeachprincipalofficer. Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ h. Ifpurchaserisacorporation,LPorLLC,providetheStateandthedateofincorporation. ________________________________________________________________________________________ (State) (DateofIncorporation) (TotalNumberofSharesOutstanding) LastyearannualreportwasfiledwithIndianaSecretaryofState ______________________ American LegalNet, Inc. www.FormsWorkFlow.com i. Listthenameofeachshareholderandthenumberofsharesheldbyeachshareholder: Name Number of Shares j. ListallothermotorcarriercompanieswhichholdIndianaIntrastateAuthorityinwhicheachshareholderhasan interest.ProvidetheIndianaintrastatecertificateorpermitnumbersheldbythesecompanies. Motor Carrier Company Certificate or Permit Number k. IfcurrentlyoperatingunderanIndianacertificateorpermit,providethenumber: CertificateNumber _____________________________ PermitNumber _______________________________ 2. Seller Information a. Seller'sName _____________________________________________________________________________ ________________________________________________________________________________________ b. StreetAddress ____________________________________________________________________________ c. City,State,ZipCode ________________________________________________________________________ d. TelephoneNumber _____________________________ County _____________________________________ e. PrincipalPlaceofBusinessinIndiana(ifotherthanabove): ________________________________________________________________________________________ (StreetAddress) (City) (State) (ZipCode) _______________________________ (County) f. CheckOne:Partnership _______ Corporation _______ Individual _______ g. Ifsellerisapartnership,givethenameandaddressofeachmemberthereof;ifsellerisacorporation,givethe name,title,andaddressofeachprincipalofficer: Name _________________________________ Address ___________________________________________ Name _________________________________ Address __________________________________________ Name _________________________________ Address __________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com h. Ifsellerisacorporation,providetheStateandthedateofincorporation. ________________________________________________________________________________________ (State) (DateofIncorporation) (TotalNumberofSharesOutstanding) LastyearannualreportwasfiledwithIndianaSecretaryofState: ____________________________________ i. ListallIndianaIntrastateAuthoritycertificateorpermitnumberswhichthesellerwillberetaining.(AttachCopies) ________________________________________________________________________________________ j. Isthesellercurrentlyinbankruptcy? Yes No Ifyes,indicatecausenumber,dateoffilingandinwhatcourtfiled:____________________________________ ________________________________________________________________________________________ k. Hasanyshareholder,partnerorownerofsellereverbeenashareholder,partnerorownerofaMotorCarrier whichhasfiledbankruptcy? Yes etethefollowing: Name of Shareholder, Partner or Owner Motor Carrier Date of Bankruptcy Petition Cause Number of Bankruptcy Petition Court Filed In NoIfyes,compl DidthismotorcarrierholdIndianaIntrastateAuthority? Yes tificateorpermitasaresultofthebankruptcy? ___________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ l. NoIfyes,whathappenedtothecer- Hasthesellerperformedcontinuousandadequateserviceunderthecertificateorpermitnowpendingsaleand transfer? _________________________________________________________________________________ m. Insupportofthisapplication,pleaseattachacopyofthecertificateorpermitbeingtransferredincludingthescope ofauthoritygrantedbytheDepartment. American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE,thejointapplicantsaskthattheIndianaDepartmentofRevenuegrant___________________________ (Emergency Temporary or Temporary) authority to purchaser pending the sale and transfer of ____________________ number ________________________ , authorizingtheoperationofmotorvehiclesasacommonorcontractcarrieroverthepublichighwaysoftheStateof Indianaupontherouteandbetweenthepointsandservingthecitiesandtownsasauthorizedbytheabovenumbered certificateorpermit. _____________________________________________ (SignatureofAttorneyorRepresentativeorPurchaser) (PrintNameofAttorneyorRepresentative) (Address) (CertificateorPermit) ___________________________________________ (SignatureofPurchaser) _____________________________________________ _____________________________________________ _____________________________________________ (TelephoneNumber) ___________________________________________ (PrintNameofPurchaser) ) ) SS: COUNTYOF____________ ) Beforemetheundersigned,aNotaryPublicfor____________________County,Stateof____________