Declaration Of Signature (Schedule S) {INIRP-S}

State Form 48284 (R2 / 8-12) INIRP-S Form International Registration Plan Declaration of Signature Schedule S IRP Account Number/Fleet Number: Indiana Telephone Number: State: Zip Code: Indiana Department of Revenue Account Name: Street Address: City: We cannot process your 20 _______ IRP transactions because you failed to sign one or more of your returns. Sign the declaration below if you want to authorize the processing of your returns, or check the Return to Sender box if you do not want us to process your application. Select one or the other, but be cautious not to select both. Taxpayer Declaration Under penalties of perjury, I declare that I have reviewed the information contained on my Indiana International Registration Plan application, including all schedules and other attachments, and to the best of my knowledge and belief it is true and complete. I also attest that I have provided proof of financial responsibility prior to affixing my signature below. I understand that my signature below allows the Indiana Department of Revenue to accept and process my IRP application in the same manner as if it had been signed upon submission. ______________________________________ Signature of Owner or Responsible Officer _______________________________ Title _________________ Date Taxpayer Declaration Return the original documents to sender. I understand that by checking this box my IRP requests will not be processed until I sign and resubmit the original document(s). I further understand that I may not have IRP apportioned plates and other credentials as anticipated. _______________________________ Title _________________ Date ______________________________________ Signature of Owner or Responsible Officer You may submit the form by: Fax (317) 615-7310 Email IndianaIRP@dor.in.gov Mail Indiana Department of Revenue Motor Carrier Services - Attn: IRP Unit 7811 Milhouse Road, Suite M Indianapolis, IN 46241-9550 American LegalNet, Inc. www.FormsWorkFlow.com