Form Tc-852 - Original Application - Schedule A - 2007

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Utah State Tax Commission - Motor Carrier Services - IRP

Clear form

Original Application - Schedule A

Telephones: (801) 297-6800 or 1-888-251-9555; Fax (801) 297-6899

TC-852 Rev. 7/07

Fleet

License year

Application effective date

Registration period (check one)

Account number

Federal ID (FEIN/EIN)

U. S. DOT number

Utah IFTA account number

UT-

MAR 31

JUN 30

Name of applicant

Business telephone number (must be a Utah number)

Person to contact regarding application

SEPT 30

DEC 31

Business street address (where records are kept - must be a Utah physical address)

Mailing street address

Contact's city

Contact's state

County

State

Contact's telephone number

Contact's fax number

City

ZIP code

City

State

ZIP code

If previously prorated in another state provide

previous state and account number

Type of operation (check the ONE that applies)

Is this an organization exempt from property tax?

State: _________________________

Do you currently have Wyoming intrastate operating authority?

only if rental

is less than

For hire

Private

Rental

Exempt

Household goods

Yes

Account no.: ____________________

45 days

Registered Weights (list on this schedule only the units that will operate at the same weight in the IRP jurisdictions) - if traveling in Quebec, list the total combined axles for power units/trailers and the gross weight for buses)

(see note)*

Power unit (total axles of power unit &

Carrier responsible

Property

Name of owner

trailer combined) -

Bus (gross weight)

Declared

License

for safety of vehicle

tax

Equipment

Unladen

combined

Y/N

Date of

Purchase

Y/N

Vehicle Identification number

Make

Year

Factory

plate

Owned

Leased

US DOT

1 yr. 2 yr.

number

weight

gross weight

***

purchase

price

number

FEIN/EIN

price

Leased

start date

end date

number

***

** Action codes: A - Add vehicle R - Renew vehicle W - Weight change C - Change vehicle

Will the control and responsibility for the safety of this vehicle be assigned to a different Motor Carrier during the registration year by lease?

Does truck pull a trailer

JURISDICTION USE ONLY

My signature below acknowledges that I understand and will comply with the reporting, payment, record keeping, and license display requirements as specified in the International Registration Plan. I understand that failure to

comply with the provisions, shall be grounds for revocation of my registrations in all member jurisdictions. Under penalty of law, I certify, under the penalties of perjury, that the information herein is true, correct, and complete.

HVUT verified ________________________

Utah Special Fuel/IFTA: I hereby certify that I have qualified with the Utah State Tax Commission and that I will make reports as required, under the federal identification number listed on this form.

Signature of person completing application

Date signed

**Fuel Key: D-Diesel G-Gasoline GH-Gasohol N-Natural P-Propane

I/M verified __________________________

**Type key: BS-Bus C-Cement Pumper CG-Converter Gear CR-Crane DB-Double Bottoms DT-Dump Truck LG-Log Truck

RT-Road Tractor TK-Truck (single) TL-Full-Trailer or

Semi-Trailer

TR - Tractor TT-Truck/Tractor W-Wellborer WK-Wrecker/Tow Truck