Form Mfut-12 - Application For Motor Fuel Use Tax Ifta License And Decals - 1999
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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.)
1
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 physical address.
Legal name ____________________________________
Trade (DBA) name __________________________________
Physical address ____________________________________________________________________________________
Number and street (required)
_________________________________________________________________________________________________
City
State
ZIP
Country
Telephone ( _____ ) _____________________
Contact person __________________________________
7
Write the name and mailing address you would like us to use to send you tax returns (if different than Line 6).
You must send us a power of attorney form if the name is different than Line 6.
Name _____________________________________________________________________________________________
Mailing address ____________________________________________________________________________________
Number and street (required)
_________________________________________________________________________________________________
City
State
ZIP
Country
8
Write the name and mailing address you would like us to use to send you decals (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
Decals are issued in one set of two decals per qualified motor
Replacement decal order
13
vehicle. Each qualified motor vehicle must have one set of
My original decal was:
___ Lost
___ Stolen
valid decals displayed.
___ Damaged
___ Other ________________________
Explain
14
Original, additional, or renewal decal order
Specify decal year of replacement decals
__ __ __ __
9
Specify decal year of requested decals
__ __ __ __
15
Total number of replacement decal sets needed
___________
10
Total number of decal sets needed
____________
16
2 00
Cost per replacement decal set
$________
___
|
11
3 75
Cost per decal set
$________
___
|
17
Multiply Line 15 by Line 16. This is your
$________
___
|
12
Multiply Line 10 by Line 11. This is your cost
cost for replacement decals.
for original, additional, or renewal decals.
$________
___
|
18
Add Lines 12 and 17. This is your
total cost of decals ordered.
$________
___
|
Make your check payable to “Illinois Department of
This form is authorized by the Illinois Motor Fuel Tax Law. Disclosure of this information
is REQUIRED. Failure to provide information could result in a penalty. This form has
Revenue.”
been approved by the Forms Management Center. IL-492-3262
Be sure to complete Step 7 on the back.
MFUT-12 Front (R-8/99)
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