Form Tc-852 - Irp Original (Schedule A) And Supplemental (Schedule C) Application (2009)

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IRP Original (Schedule A) and Supplemental (Schedule C) Application
TC-852
Rev. 8/09
Registrant fleet account number
Fleet number
License year
Application effective date
UT-
Federal ID (FEIN/EIN)
U.S. DOT number
Utah IFTA account number
Name of registrant
D.B.A., if any
Registrant phone no. (must be a Utah number)
Registrant street address (where records are kept - must be a Utah physical address)
Person to contact regarding application
City
County
State
Contact's city
Contact's state
ZIP code
UT
Contact's phone no.
Fleet (situs) permanent address (if different than registrant above)
Contact's fax no.
State
City
County
ZIP code
If previously prorated in another state provide previous state and account number
UT
State:
Account no.:
Mailing address
Type of operation (check the ONE that applies)
only if rental
is less than
For hire
Private
Rental
45 days
City
State
ZIP code
Exempt
Household goods
Registration period (check one)
Is this an organization
Do you currently have
exempt from property tax?
Yes
Yes
No
Wyoming intrastate
No
MAR 31
JUN 30
SEPT 30
DEC 31
operating authority?
T
Weight group #
Type (
B
-Bus -Powe
P
r
-Trailer)
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.
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
NC
MA
OH
TX
AB
ON
CA
IA
MD
ND
OK
UT
BC
QC
CO
ID
ME
NE
OR
MB
VA
SK
IL
MI
NH
CT
PA
VT
NB
YT
IN
MN
NJ
RI
DC
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
Make
Year
Fuel
Type
For Office Use Only
Do not
renew
1 Yr. Pro. tax _______
Unladen weight Decl. comb. gross
Axles/Seats
Name of titled owner/lessor
2 Yr. Pro. tax _______
wgt
HVUT verified _______
Situs of vehicle (physical location of vehicle if different than fleet)
I/M # verified _________
Inspec # verified _________
City
County
State
Select plate type
ZIP code
LE Skier
LE Arches
Title verified ___________
Lease start date Lease end date
Owned/Leased
FEIN/EIN of carrier responsible for vehicle safety US DOT number
Vehicle safety changed?
Factory price ____________
Yes
No
Sales tax Y/N _______
Truck pull trailer?
Less than 10K/miles Plate Title Temp.
Purchase price
License plate number
Purchase date
Curr. veh. value___________
Yes
No
Continue equipment information on next page

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