Form Tc-852 - Irp Original And Supplemental Application Forms
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TC-852
IRP Original (Schedule A) and Supplemental (Schedule C) Application
Rev. 10/16
Registrant fleet account number
Fleet number
License year
Application effective date
UT -
Federal ID (FEIN/EIN)
USDOT number
Utah IFTA account number
Name of registrant
DBA (if any)
Registrant phone (must be a Utah number)
Registrant street address (where records kept - must be a Utah physical address)
Contact person regarding application
City
County
State
ZIP code
Contact’s city
Contact’s state
UT
Fleet (situs) permanent address (if different from above)
Contact’s phone
Contact’s fax
City
County
State
ZIP code
If previously prorated in another state, provide previous state and account number.
UT
State:
__ __ __
Account #:
__ __ __ __ _ _ _ _ _ _ _
Mailing address
Type of operation (check ONE)
Rental (only if rental
For hire
Private
is less than 45 days)
City
State
ZIP code
Household goods
Exempt
Registration period (check ONE)
Organization exempt from property tax?
Currently have Wyoming intrastate operating authority?
MAR 31
JUNE 30
SEPT 30
DEC 31
Yes
No
Yes
No
Registered Weights
List below 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.
Weight group #:___ __ __ __ _ _ __ _ __ _ __ ____
Type (B - Bus; P - Power; T - Trailer):_ _ __ _ __ _ _____
AK
DE
KS
MO
NM
SC
WI
NS
AL
FL
KY
MS
NV
SD
WV
NT
AR
GA
LA
MT
NY
TN
WY
PE
AZ
HI
MA
NC
OH
TX
AB
ON
CA
IA
MD
ND
OK
UT
BC
QC
CO
ID
ME
NE
OR
VA
MB
SK
CT
IL
MI
NH
PA
VT
NB
YT
DC
IN
MN
NJ
RI
WA
NF
MX
Equipment Information
Action codes: A - Add vehicle; R - Renew vehicle; W - Weight change; C - Change vehicle (may not add units on a renewal)
Fuel key: D - Diesel; G - Gasoline; GH - Gasohol; N - Natural; P - Propane; F - Flex fuel
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
Action code
FT equipment number
Vehicle identification number
Type
Make
Year
Fuel
Office Use Only
Do not renew
_ _ _ _ _ _
1 Yr. Pro. tax
Axles/Seats
Name of titled owner/lessor
Unladen weight
Decl. comb. gross wgt.
_ _ _ _ _ _
2 Yr. Pro. tax
_ _ _ _ _
HVUT verified
Situs of vehicle (physical location of vehicle, if different from fleet)
City
State
County
ZIP code
_ _ _ _ _ _
I/M # verified
_ _ _ _
Plate type
Owned/Leased
Lease start date
Lease end date
Inspec # verified
LE Skier
LE Arches
_ _ _ _ _ _
Title verified
FEIN/EIN of carrier responsible for vehicle safety
USDOT number
Vehicle safety changed?
_ _ _ _ _ _
Factory price
Yes
No
_ _ _ _ _
Sales tax Y/N
Truck pull trailer? Less than 10K miles? Plate
Title
Temp.
License plate number
Purchase date
Purchase price
_ _ _ _ _
Curr. veh. value
Yes
No
Equipment Information continued on next page
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