Proportional Use Credit Certification Application {PROP-1}

State Form 55615 (R4 / 2-16) PROP-1 Proportional Use Credit Certification Application Due April 1 Fee $7 Indiana Department of Revenue Complete this section only if different from Lines 1, 3, 5, 6, and 7. 1. Legal Name 3. Physical Address 5. City 11. County 15. DOT Number 6. State/Province 7. ZIP Code 2. Doing Business As (DBA) 4. Mailing Address 8. City 9. State/ Province 10. ZIP Code 12. Telephone Number 16. TID Number 13. Federal Identification Number 14. Social Security Number 17. Base State/Jurisdiction 18. Email Address Note: If you have IFTA in another jurisdiction, proceed to Line 19. All others go to Line 21. 19. Check the type of organization of this business Sole Proprietorship Partnership 20. Corporations must provide the following information: State of Incorporation Date Authorized to Do Business Corporation Government Other ______________________ State of Commercial Domicile Accounting Period Year Ending Date (MM/DD) Date of Incorporation Corporation - List Names of Owner, Partners, or Officers (attach additional sheets if necessary) Last Name, First, Middle Initial Title Street Address City State ZIP Code Social Security Number I do hereby certify under penalty of perjury that the foregoing and attached information is a true and correct statement to the best of my knowledge and is a complete and full representation based on the best information available. _________________________________________________________ 21. Signature ______________________________________________ Typed or Printed Name ____________________________ Date __________________________ Telephone Number ________________________ Title This application MUST be signed by the owner, general partner, or corporate officer before it will be processed by the department. For more information regarding this application, you may contact the department at (317) 615-7345. Mail the completed application, all relevant documentation, and application fees to: Indiana Department of Revenue Motor Carrier Services Division 7811 Milhouse Rd Suite M Indianapolis, IN 46241-9612 American LegalNet, Inc. www.FormsWorkFlow.com Vehicle Information This section must be completed by all applicants. If you have more than 5 vehicles, please attach printout. Vehicle Code Vehicle VIN Year Vehicle Type Vehicle Axles Seats Make Fuel Unladen Weight Gross Weight MSRP Line-By-Line Instructions Line 1 - Enter the legal name or sole proprietorship, partnership, corporation, or other legal name. Lines 3, 5, 6, 7, and 11 - Enter the actual location of your business by providing the street address, city, state/province, ZIP Code, and county* (*Indiana businesses only). Lines 2, 4, 8, 9, and 10 - Enter the appropriate information ONLY if different from Lines 1, 3, 5, 6, 7, and 11. Line 12 - Enter the area code and telephone number of your principle place of business. Line 13 - Enter your 9 digit federal identification number. Line 14 - Enter your Social Security number if your business does not have a federal identification number. Line 15 - Enter your Interstate U.S. DOT number. Line 16 - Enter your TID number. Line 17 - Enter the base state/jurisdiction in which you have your IFTA registered. Line 18 - Enter an email address to send/receive correspondence to/from the department. Line 19 - To be entered by non-Indiana carriers only. Check the appropriate business type here. If a corporation, complete Line 20. All others go to Line 21. Line 20 - Enter the requested information. This certificate will not be processed without this section completed. Line 21 - Enter the signature of the taxpayer/authorized agent. Code 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 71 72 73 List of Eligible Vehicles Air Conditioning Unit for Buses .................................... 10% Bookmobile .................................................................. 35% Boom Truck-Block Boom ............................................. 20% Bulk Feed Truck ........................................................... 15% Car Carrier with Hydraulic Winch................................. 10% Carpet Cleaning Van.................................................... 15% Cement Mixer .............................................................. 30% Distribution Truck-Hot Asphalt ..................................... 10% Dump Trailer ................................................................ 15% Dump Truck ................................................................. 23% Fire Truck ..................................................................... 48% Leaf Truck .................................................................... 20% Lime Spreader ............................................................. 15% Line Truck-Digger/Derrick, Aerial Lift Truck ................. 20% Milk Tank Truck ............................................................ 30% Mobile Crane ............................................................... 42% Pneumatic Tank Truck ................................................. 15% Refrigeration Truck ...................................................... 15% Salt Spreader-Dump with Spreader ............................. 15% Sanitation Dump Trailers ............................................ 15% Sanitation Truck ........................................................... 41% Seeder Truck ............................................................... 15% Semi Wrecker .............................................................. 35% Service Truck with Jackhammer, Pneumatic Drill ........ 15% Sewer Cleaning Truck Sewer Jet, Sewer Vactor ......... 35% Snow Plow ................................................................... 10% Spray Truck.................................................................. 15% Super Sucker ............................................................... 90% Sweeper Truck ............................................................. 20% Tank Truck ................................................................... 24% Tank Transport ............................................................. 15% Truck with Power Take-off Hydraulic Winch................. 20% Wrecker ....................................................................... 10% Auxiliary Power Unit (APU) ............................................ 4% Stone Slinger ............................................................... 35% Diesel Particulate Filter ........................