Unified Carrier Registration {BAS-2}

UNIFIED CARRIER REGISTRATION PROGRAM IMPORTANT NOTICE FOR ALL INTERSTATE MOTOR CARRIERS, FREIGHT FORWARDERS, BROKERS & LEASING COMPANIES If you operate a tractor, truck or bus in interstate or international commerce, the registration requirements of the Unified Carrier Registration Agreement (UCR) apply to your business. The Unified Carrier Registration (UCR) requires individuals and companies that operate commercial motor vehicles in interstate or international commerce to register their business with Indiana and pay an annual fee based on the size of their fleet. Motor private carriers of passengers only are not required to register and pay fees under the UCR. The revenues generated will be used for enforcement of motor carrier safety programs. Companies operating solely as brokers, freight forwarders or leasing companies are also required to register and pay a fee of $76. Companies providing both motor carrier services as well as broker, freight forwarder or leasing services are required to pay the fee level set at the motor carrier level. ***If the carrier only operates small vehicles (gross vehicle weight rating or gross weight rating of less than 10,000 lbs.), its fleet size for UCR purposes would be zero and they would register and pay in the lowest fee category (currently $76). You must register for calendar year 2017 by November 30, 2016 in order to be in compliance by January 1, 2017. NOTE: You must maintain a list of vehicles you have excluded for UCR. The UCR1 form is available on-line at www.ucr.in.gov. UCR System Mobile Version is Now Available! -- Motor carriers can now register and pay for their Unified Carrier Registration using their smart phone 24/7, 365 days a year. THE FEE BRACKETS FOR MOTOR CARRIERS, FREIGHT FORWARDERS, BROKERS OR LEASING COMPANIES ARE AS FOLLOWS: Fleet Size Fee per Company ----------------------------------------------------------------------0-2 $ 76.00 3-5 $ 227.00 6 - 20 $ 452.00 21 - 100 $ 1,576.00 101 - 1,000 $ 7,511.00 1,001 - Over $ 73,346.00 Example: A broker also offering services as a motor carrier operating four tractors and nine straight trucks has a fleet size of thirteen commercial motor vehicles and pays $452.00. IMPORTANT NOTICE: If you operated in 2016 you must pay your 2016 UCR fees. To avoid delays it is highly recommended that you register on-line at www.ucr.in.gov and follow the step by step instructions. Payments may be made on-line using MasterCard, Visa Discover or E-Check. Please note, if you pay via credit card you will be charged an access fee based on the total bill. If you pay by E-Check you will incur a $1 fee. If you would like to mail in your application you may go to http://www.in.gov/dor/4195.htm or http://www.ucr.in.gov to print out the BAS-2 form. Make checks payable to the Indiana Department of Revenue. If you would like the form mailed to you contact the Indiana Motor Carrier Services Division at (317) 615-7350. Indiana Department of Revenue Motor Carrier Services Division Insurance and Safety Section P. O. Box 6075 Indianapolis, IN 46206-6075 American LegalNet, Inc. www.FormsWorkFlow.com Form BAS-2 State Form 46139 (R11 / 10-16) Indiana Department of Revenue UNIFIED CARRIER REGIS TRATION FORM -Year 2017 Motor Carrier Services Division P. O. Bo x 6075 Indianapolis, IN 46206-6075 FF Number Telephone Number Fax Number SECTION 1. GEN ERAL INFORMATION USDOT Number MC or MX Number Legal Name Email Address Doing Business Under The Following Name (DBA) Principal Place Of Business Street Address (See Instructions) Principal Business City Principal Business State Zip Code Mailing Street Address Mailing City Mailing State Mailing Zip Code SECTION 2. CLASSIFICATION ­ Check All That Apply Motor Carrier Motor Private Carrier Broker Leasing Co mpany SECTION 3. FEES DUE-B ROKERS , FREIGHT FORWARDERS AND LEAS ING COMPANIES ONLY Freight Forwarder Note: If your company is also a motor carrier or motor private carrier, skip this section and go to section 4. Bro kers, freight forwarders and leasing co mpanies (not combined with a motor carrier entity), please submit the amount due of $76 in the form of pay ment acceptable by your base state and go to Section 7. SECTION 4. NO. OF MOTOR VEHICLES­ MOTOR CARRIER & MOTOR PRIVATE CARRIER Check only one box: Option A Option B LINE NO . 1. The number of vehicles shown below has been taken from section 26 of your last reported M CS-150 form. The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30, 2016. NUMBER O F STRAIGHT TRUCKS AND TRACT RS (COLUMN A) O NUMBER O F MO T OR COACHES, SCHOO L BUSES, MINI-BUSES, VANS AND LIMO USINES (CO LUMN C) See Instructions for additional requirements if you select Option B. TOTAL (CO LUMN D) (CO LUMN B) 2. 3. Subtract: (A) The number of vehicles on Line 1 i n Column C above that has a vehicle capacity of 10 or less passengers, includi ng the dri ver. (B) (Optional )The number of vehicles on Line 1 in Col umn A above that are used exclusi vely i n intrastate transportati on. You are required to maintain a list of vehicles excluded under this option. See Instructions for additional requirements if you select this option. (Optional) Add a number of vehicles not shown on Line 1 above that are: (A) Commerci al motor vehicles operating exclusi vely in intrastate commerce. (See i nstructions for definition of commercial motor vehicle.) (B) Used i n commerce to transport passengers or property for compensati on and have a GVWR or GVW of 10,000 lbs or less, or a passenger capacity of 10 or less, including the dri ver. ( ) 4. Total Number of Vehicles (Line 1 minus Line 2 plus Line 3) Number of Vehicles 101-1000 1001 or more SECTION 5. FEE TABLE Number of Vehicles 0-2 3-5 Amount Due $76 $227 Number of Vehicles 6-20 21-100 Amount Due $452 $1,576 Amount Due $7,511 $73,346 SECTION 6. FEES DUE ­ MOTOR CARRIER & MOTOR PRIVATE CARRIER Using the number of vehicles in Section 4, Line 4 above, enter the Amount Due fro m the table above. Note: See last page of this pamphlet for the types of payment your selected base state will accept. SECTION 7. CERTIFICATION Name Of Owner Or Authorized Representative (Printed) $ I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute and file this document on behalf of the applicant. (Penalty provisions subject to the laws of the registration state.) Date Signature Title American Legal