Form Irp-5-Schedule B Mileage Information

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New York State Department of Motor Vehicles

IRP-5 (4/09)

DMV USE ONLY

INTERNATIONAL REGISTRATION PLAN

SCHEDULE B MILEAGE INFORMATION

SUPP#: __________________

31. REG YEAR: __________ 32. ACCOUNT #:__________________ 33. FLEET #:_________ 34. CARRIER ________________________________

(35)

(36)

(37)

PRORATE?

STATE

ACTUAL

ESTIMATED

PRORATE?

STATE

ACTUAL

ESTIMATED

Yes/No

MILEAGE

Yes/No

MILEAGE

AK (Alaska)

NV (Nevada)

AL (Alabama)

NY (New York)

AR (Arkansas)

OH (Ohio)

AZ (Arizona)

OK (Oklahoma)

CA (California)

OR (Oregon)

CO (Colorado)

PA (Pennsylvania)

CT (Connecticut)

RI (Rhode Island)

DC (Dist. of Col.)

SC (South Carolina)

DE (Delaware)

SD (South Dakota)

FL (Florida)

TN (Tennessee)

GA (Georgia)

TX (Texas)

IA (Iowa)

UT (Utah)

ID (Idaho)

VA (Virginia)

IL (Illinois)

VT (Vermont)

IN (Indiana)

WA (Washington)

KS (Kansas)

WI (Wisconsin)

KY (Kentucky)

WV (West Virginia)

LA (Louisiana)

WY (Wyoming)

MA (Massachusetts)

MX (Mexico)

MD (Maryland)

CANADA

ME (Maine)

AB (Alberta)

MI (Michigan)

BC (British Columbia)

MN (Minnesota)

MB (Manitoba)

MO (Missouri)

NB (New Brunswick)

NL (Newfoundland/

MS (Mississippi)

Labrador)

MT (Montana)

NS (Nova Scotia)

NC (North Carolina)

NT (Northwest Terr.)

ND (North Dakota)

ON (Ontario)

NE (Nebraska)

PE (Prince Edward Isl.)

NH (New Hampshire)

QC (Quebec)

NJ (New Jersey)

SK (Saskatchewan)

NM (New Mexico)

YT (Yukon)

38. ESTIMATED MILEAGE:_____________

39. ACTUAL MILEAGE:_____________

40. TOTAL OF ALL MILEAGE: _______________

41. NOTE: For any Estimated Mileage shown above, you must explain why you are using estimated mileage. This explanation needs to include

information such as business purposes, contracts, number of anticipated trips and route information (a separate sheet of paper may be used if

necessary).

CERTIFICATION: I certify that the information provided on this mileage schedule is true and correct. I certify that the actual distance reported on this

form is supported by my distance records and they must be maintained in compliance with IRP recordkeeping requirements and retained for 6 years from

the trip date. I understand that my distance records are subject to audit any time and will make these records available. I will pay all auditor travel expenses

if my distance records cannot be made available. I understand that additional fees will be assessed and/or my IRP account will be suspended or canceled

if my distance records are not made available and/or I do not comply with IRP Requirements.

Signature

TITLE: (If signing for a corporation)

Date

(President, Vice-President, Secretary, Treasurer, or Comptroller. Anyone

PAGE 1 0F 2

else signing for a corporation must send in an original Power of Attorney

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