Form 2824 - Application For Replacement Claiming Lost, Destroyed, Undelivered Or Stolen State Of Michigan Ifta Fuel Decal(S) 2009

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Michigan Department of Treasury

Clerk's Initials

2824 (Rev. 7-09)

Application for Replacement Claiming Lost, Destroyed,

Date

Undelivered or Stolen State of Michigan IFTA Fuel Decal(s)

Issued under P.A. 119 of 1980. Filing is voluntary.

INSTRUCTIONS: Use this form to request a replacement for any lost, destroyed, stolen or undelivered IFTA Decals. Also use this form to request a

replacement for decals from a licensed vehicle which is sold. The decal should be torn from the sold vehicle and destroyed. The buyer of the vehicle

must be identified in number 11 below. Please print or type.

1. Complete Company Name (include Corp., Inc., P.C., L.L.C., etc.)

2. Account Number (FEIN, ME, TR, IFTA)

3. Business Name, Assumed Name or DBA (if used)

4. IRP Number

5. Address (Number and Street or RR#, City, State, Zip)

6. Decal Year

7. Quantity of Decals

8. Phone Number

9. Enter below the serial number(s) of the fuel decal(s) that are being replaced. (Required if decal lost, destroyed, stolen or vehicle disposed of or sold)

I certify the following:

10.

that I am the licensee or authorized representative of the licensee named above and that the decals listed above have been:



lost

destroyed

undelivered

stolen

that I have sold or disposed of and replaced a licensed vehicle and have removed and destroyed its decal. The vehicle I

11.



sold or disposed of is now owned by (name, address, city, state, ZIP):