Free New Operation Schedule B-Wisconsin IRP Application - Wisconsin

Clear Form
MV2854
Account No

NEW OPERATION SCHEDULE B
Wisconsin IRP Application
US DOT Number Registrant Area Code - Telephone Number

7/2004

Ch. 341 Wis. Stats.
Fleet No Operation Start Date Federal Employer ID No / WI IFTA

Submit To: Wisconsin Department of Transportation-IRP Unit E-mail: [email protected] P. O. Box 7955 608-266-9900 Madison, WI 53707-7955

Operation Type Private For Hire Authority Number Household Goods

WI
Registrant Name Registrant Area Code - FAX Number

Business Type Sole Owner Partnership Corporation LLC LLP

Street Address

City

State

ZIP Code

Contact Person - Regarding Application

Billing Address

City

State

ZIP Code

Contact Person Area Code - Telephone Number

Rental Company
Have you ever had IRP registration under this name?

Vehicle(s) Previously Registered Fuel Tax is required - Are you responsible for filing your Fuel Tax reports? Check One

Yes, Give State / Account Number No

WI Base Plate WI IRP Plate In Another State Just Purchased

Yes No, Give Name and Company FEIN
Provide a copy of the lease or a statement on lessee's letterhead stating that they are responsible for filing your fuel tax and supplying you with IFTA decals.

Owner/Operator Lessee Name:

Place an X in the box to the left of each jurisdiction where you will be operating your vehicle(s). Shaded boxes are not IRP jurisdictions. I am providing my own estimated mileage to Wisconsin. The justification is attached. I am accepting Wisconsin's estimated mileage chart. MILEAGE X JURISDICTION EST X MILEAGE MILEAGE JURISDICTION EST X JURISDICTION AB- Alberta MD- Maryland X OK- Oklahoma 30 430 X 1010 AK- Alaska ME- Maine X ON- Ontario 10 160 X 540 AL- Alabama MI- Michigan X OR- Oregon 670 2600 X 320 AR- Arkansas MN- Minnesota X PA- Pennsylvania 840 3980 X 2720 AZ- Arizona MO- Missouri X PE- Prince Edward Is. 820 1920 X 10 BC- British Columbia MS- Mississippi X QC- Quebec 290 640 X 90 CA- California MT- Montana X RI- Rhode Island 1550 770 X 40 CO- Colorado MX- Mexico X SC- South Carolina 410 10 X 650 CT- Connecticut NB- New Brunswick X SD- South Dakota 270 20 X 600 DC- District Columbia NC- North Carolina X SK- Saskatchewan 10 1160 X 950 DE- Delaware ND- North Dakota X TN- Tennessee 70 420 X 1640 FL- Florida NE- Nebraska X TX- Texas 1060 1020 X 2170 GA- Georgia NH- New Hampshire X UT- Utah 1870 80 X 740 IA- Iowa NJ- New Jersey X VA- Virginia 2300 520 X 920 ID- Idaho NL- Newfoundland X VT- Vermont 370 10 X 110 IL- Illinois NM- New Mexico X WA- Washington 8210 710 X 490 IN- Indiana NS- Nova Scotia X WI- Wisconsin 5340 10 X 20160 KS- Kansas NT- Northwest Terr. X WV- West Virginia 700 10 X 500 KY- Kentucky NU- Nunavut X WY- Wyoming 1710 10 X 1110 LA- Louisiana NV- Nevada X YT- Yukon Territory 440 620 X 10 MA- Massachusetts NY- New York X 350 1170 X TOTAL FLEET MILES MB- Manitoba OH- Ohio X 320 4090 X I certify with penalty of perjury that the information furnished on this application and the attached schedules, if applicable, is true and correct, and that I have knowledge of the applicable Federal and State safety regulations and equipment requirements for the operation of commercial motor vehicles.

State: Federal Employer ID Number - list below

EST Area Below For DOT Use Only X X X X X X X X X X X X X X X X X X X X Application Billed
(IR Number)

Under Wisconsin's Open Records Law, the Department may make nonconfidential motor vehicle information available to companies and others who use the data for business purposes. If your IRP registration is in your personal name and you want your name and address withheld from such companies/groups, please obtain form MV3592, Request to Withhold Name and Address. If you have questions about this option, call 608-266-1466.

X
(Registrant Signature) (Date)

NEW OPERATION SCHEDULE A
TYPE CODE TT - Truck Tractor RT - Road Tractor WEIGHT CODE Unladen Weight Gross Weight TK - Straight Truck BS - Bus HS - Hot Shot WR - Wrecker FUEL CODE D - Diesel G - Gasoline P - Propane A - Alternative

= Empty weight of vehicle = Truck Tractor is the weight of the POWER UNIT axles only, with the loaded semi-trailer attached. Straight Truck is the loaded weight of the vehicle. Combination Weight = Truck Tractor and semi-trailer combined weight (WI maximum is 80,000) Straight Truck (loaded) and full trailer loaded weight (for jurisdictions other than WI)

If you have a STRAIGHT TRUCK, does it pull a FULL TRAILER? _____ No _____ Yes, then list BOTH the gross and combination (Comb) weights.
Y E A R (2) T Y P E (5) A X L E S (6) S E A T S (7) F U E UNLADEN WT L (9) (8)

Clear form

UNIT EQUIP NO (1)

MAKE (3)

VEHICLE IDENTIFICATION NO (4)

GROSS WT (10)

COMB GW (11)

TITLED OWNER NAME (IF LEASED) (12)

PURCHASE DATE MO/YR (13)

OWNER PURCHASE PRICE (14)

FACTORY LIST PRICE (15)

CO X