Form Mfut-12 - Application For Motor Fuel Use Tax Ifta License And Decals January 2005
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1
2Illinois Department of Revenue
MFUT-12
Application for Motor Fuel Use Tax
IFTA License and Decals
Do not write above this line.
Step 1: Write your carrier account numbers
(Please type or print in ink.)
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3
FEIN/SSN _____________________________________
IRP no.
___________________________________
Federal employer identification number/Social Security number
Illinois international registration plan firm number
2
4
IBT no.
_____________________________________
US DOT no. ___________________________________
Illinois business tax number (if applicable)
United States Department of Transportation number
Step 2: Check your application type
(Check all that apply.)
5
___ Original application
___ Ordering additional or replacement decals
___ Renewal application
___ Correcting account information
Step 3: Identify your business
6
Write your business’ name and address. A physical address is required. Post Office box numbers will not be accepted.
Legal name: ____________________________________
Trade (DBA) name: __________________________________
Street address:______________________________________________________________________________________
Number and street (required)
_________________________________________________________________________________________________
City
State
ZIP
Country
Telephone: (_____)______ - ___________
Contact person: _________________________________
7
Write the name and mailing address where you want your tax returns sent (if different than Line 6). If the name is different
than Line 6, a power of attorney form must also be attached.
Name:
_____________________________________________________________________________________________
Mailing address:_____________________________________________________________________________________
Number and street (required)
_________________________________________________________________________________________________
City
State
ZIP
Country
8
Write the name and mailing address where you want your decals sent (if different than Line 6).
Name: __________________________________________________________________________________________________
Mailing address:_____________________________________________________________________________________
Number and street are required. Post office boxes cannot be accepted.
_________________________________________________________________________________________________
City
State
ZIP
Country
Step 4: Complete your decal order
You must purchase and display one set of two decals for each of your qualified motor vehicles.
Original, additional, or renewal decal order
Replacement decal order
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Specify decal year of requested decals: ___ ___ ___ ___
My original decal was: ___ Lost ___ Stolen ___ Damaged
___ Other. Explain: _______________________________
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Total number of decal sets needed:
_______________
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My original decal serial number was _________________
3 75
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Cost per decal set:
$__________
_____
(Attach additional sheet if multiple decals are being replaced.)
|
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$__________
_____
Specify decal year of replacement decals: ___ ___ ___ ___
Multiply Line 10 by Line 11.
|
This is your
cost for original,
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:
_____________
additional, or renewal decals.
Total number of decal sets needed
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Cost per decal set:
$________
2 00
____
|
Make your check payable to
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Multiply Line 16 by Line 17. This is your
$________
____
|
“Illinois Department of Revenue.”
cost for replacement decals.
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Add Lines 12 and 18. This is your total
$________
____
|
Turn to complete form.
cost of decals ordered.
This form is authorized by the Illinois Motor Fuel Tax Law. Disclosure of this information is REQUIRED. Failure to provide
MFUT-12
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-3262
(R- 01/05)
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