Form R-5678-L - International Fuel Tax Agreement (Ifta) Application
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2R-5678-L (2/02)
State of Louisiana
Department of Revenue
International Fuel Tax Agreement (IFTA) Application
Telephone (225) 219-7656
TDD (225) 219-2114
Application Fee: $35.00
Make address
Account number
changes in area
provided on back
and mark here.
Legal name
Trade name
Address
City, state, ZIP
Contact person ___________________________________ Telephone _______________________________
Date of application ________________________________ Telefax _________________________________
Type of ownership: ❏ Individual
❏ Partnership
❏ Corporation
❏ Other
Federal ID No.
SS No.
SIC No.
List Interstate Commerce Commission Motor Carrier (ICC) Number ____________________________________
List International Registration Plan (IRP) Number __________________________________________________
All corporations must provide the following information:
State of incorporation _________________________
Date of incorporation ________________________
State of commercial domicile ___________________
Fiscal year ending date ______________________
If not incorporated in Louisiana, indicate date authorized to do business in Louisiana ___________________
List name(s) of owner, partners, or officers. (Attach a separate sheet, if necessary.)
Last name
First name
Title
Street
City
State
ZIP
Social Security Number
❑
❑
❑
❑
❑
❑
Types of fuel used:
Diesel
Gasoline
Gasohol
Propane
LNG
CNG
❑
❑
❑
❑
❑
(Check all that apply.)
Ethanol
Methanol
E-85
M-85
A-55
Indicate with an “x” all jurisdictions in which you are operating, and in which you maintain bulk fuel storage
(OP = Operate; BF = Bulk Fuel Storage).
OP
BF
Jurisdiction
OP
BF
Jurisdiction
OP
BF
Jurisdiction
OP
BF
Jurisdiction
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8905
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