Free MV2667 Wisconsin Interstate Fuel Tax License Application - Wisconsin


File Size: 120.9 kB
Pages: 2
Date: July 28, 2008
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 914 Words, 5,682 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/business/carriers/forms/mv2667.pdf

Download MV2667 Wisconsin Interstate Fuel Tax License Application ( 120.9 kB)


Preview MV2667 Wisconsin Interstate Fuel Tax License Application
WISCONSIN INTERNATIONAL FUEL TAX LICENSE APPLICATION
Wisconsin Department of Transportation MV2667 8/2005 s.341.45 Wis. Stats. 1. Application Type - Check One Original FEIN Change Additional Decals Replacement License 3. Licensee Legal Name

Instructions

Clear form

Name Change Reinstatement

2. Business Type - Check One Corporation Individual Partnership Trust 4. Trade/DBA Name - If different from legal name

LLC LLP

5. Area Code ­ Telephone Number

6. Contact Person - Area Code ­ Telephone Number

7. Physical Address: Street

City

State

ZIP Code

8. Mailing Address: Street

City

State

ZIP Code

9. Federal Employer Identification Number (FEIN)

10. Social Security Number ­ For Identification Purposes (IF NO FEIN)

11. Base State IRP Account Number

12. US DOT Number - Private or For Hire Carriers Only

13. Intended Operations - Indicate the jurisdictions in which you intend to operate for IFTA WI AB AL AZ AR BC CA CO ID IL IN IA KS KY LA MA MN MO MS MT NB NC ND NE NS NV NY OH OK ON OR PA SD SK TN TX UT VA VT WA 14. Bulk Fuel Storage

CT MB NF PE WV

DE MD NH QC WY

FL ME NJ RI

GA MI NM SC

IFTA ­ Do you have bulk fuel storage? No Yes ­ If so, in which IFTA jurisdictions? 15. Fuel Types - Indicate the type of fuel your vehicles use (D) Diesel (G) Gasoline (P) Propane (GH) Gasohol

(NG) Natural Gas

16. Start Operations Date ­ REQUIRED - This is a liability date and you are held accountable for filing requirements Give Month / Day / Year

17. Fee Calculations:

A. Application Fee B. License Fee C. Number of (QMV'S) requiring fuel decals X $2.00 x $2.00 D. Additional Decal Order E. Reinstatement Fee F. Total Fee Enclosed

$15.00 3.00

25.00

Your fuel license and decals will be sent to your mailing address.

Certification I certify with my signature that to the best of my knowledge the information and statements on this application are true and correct. I agree to comply with reporting, payment, record keeping and display requirements specified by the Wisconsin Department of Transportation. I also agree that Wisconsin may withhold any refunds if I become delinquent in payment of fuel taxes, whether due Wisconsin or any IFTA member jurisdictions. I understand that failure to comply with these provisions shall be grounds for revocation of my fuel tax license and other licenses in my name and that of my corporation.

(Licensee, Authorized Representative, or Attorney-in-Fact Signature)

(Date)

Print

FUEL TAX LICENSE APPLICATION INSTRUCTIONS
1. Application Type: Original ­ First application that requests general information about the licensee and its operations. FEIN Change -- Used when your account changes the FEIN number due to name change or when you change from your social security number to the FEIN number. Name Change - Used to update your name. Additional Decals ­ Allows you to order additional decals (no application or license fee is required). Replacement License ­ Used when you loose the original license. Reinstatement ­ This restores your account to good standing after revocation of your license. This is the type of operation for which you are applying. The legal name of how your operation will be filing.

2. 3.

Business Type: Licensee Legal Name: Trade/DBA Name: Telephone Number: Contact Person: Physical Address: Mailing Address: Federal Employer Identification Number: Social Security Number: Base State IRP Account Number: US DOT Number:

4. 5. 6. 7. 8. 9.

The business name under which you operate. Complete only if different from the legal name. A telephone number where you can be reached if there are questions regarding your application. The name of the individual filing your application in case there are questions regarding your application. The address where records are kept for the licensee's vehicles. Complete only if different from the physical address. All letters and reporting forms will be sent here. This is the licensee's 9-digit number issued by the Internal Revenue Service.

10.

Complete only if you are a sole proprietor with no employees and you are not required to obtain a FEIN.

11.

This is the International Registration Plan account number issued by the jurisdiction in which your vehicles are registered. A number assigned by the U.S. government for Private & For Hire Carriers who operate vehicles over 10,000 lbs. Indicate all IFTA member jurisdictions in which you intend to operate this filing year. Indicate the jurisdictions where you maintain bulk fuel. Indicate the type of fuel your vehicles use. The liability date that you intend to start operations. This date holds you accountable for filing requirements. A. B. C. D. E. F. Application Fee: License Fee: Number of vehicles requiring fuel decals: Additional Decal Order: Reinstatement Fee: Total Fee: A $15.00 fee is required on original application, and when your account is reopened after being closed. A $3.00 fee is charged on original application, when a name change occurs, or when the original license is lost. A $2.00 decal fee will be charged for each vehicle. Refunds are not available for unused decals. A $2.00 decal fee is charged for additional decals requested. A $25.00 fee is charged when you need to reinstate your IFTA account once it has been revoked. Add the amounts A through E and submit along with your application. Registration Fee Trust Wisconsin Department of Transportation Motor Carrier Registrations 4802 Sheboygan Ave. PO Box 7979 Madison, WI 53707-7979 Telephone: 608-266-9900

12.

13. 14. 15. 16.

Intended Operations: Bulk Fuel Storage: Fuel Type: Start Operations Date: Fee Calculations:

17.

Make check payable to: Mail application and payment to:

Questions?