Fillable Form Mv-Iucr - Unified Carrier Registration Form printable pdf download

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Form MV-IUCR (Rev. 05/2013)

UNIFIED CARRIER REGISTRATION FORM

Georgia Department of Revenue

P. O. Box 740382

To register online go to

https://

Atlanta, Georgia 30374-0382

E-mail:

commercial.vehicles@dor.ga.gov

SECTION 1. GENERAL INFORMATION

USDOT Number

MC or MX Number

FF Number

Telephone Number

Fax Number

E-Mail Address

Legal Name

Doing Business Under The Following Name (DBA)

Principal Place Of Business Street Address (See Instructions)

Principal Business City

Principal Business State

Zip Code

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

SECTION 2. CLASSIFICATION – Check All That Apply

Motor Carrier

Motor Private Carrier

Broker

Leasing Company

Freight Forwarder

SECTION 3. FEES DUE-BROKERS, FREIGHT FORWARDERS AND LEASING COMPANIES ONLY

Note: If your company is also a motor carrier or motor private carrier, skip this section and go to section 4.

Brokers, freight forwarders and leasing companies (not combined with a motor carrier entity), please submit the amount due of $76 in

the form of payment acceptable by your base state and go to Section 7.

SECTION 4. NO. OF MOTOR VEHICLES– MOTOR CARRIER & MOTOR PRIVATE CARRIER

Check only one box:

Option A

The number of vehicles shown below has been taken from section 26 of your last reported MCS-150 form.

Option B

The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30 of the year

prior to this current registration year.

See Instructions for additional requirements if you select Option B.

LINE

NUMBER OF STRAIGHT TRUCKS

NUMBER OF MOTOR COACHES, SCHOOL

TOTAL

NO.

AND TRACTORS (COLUMN A)

(COLUMN B)

BUSES, MINI-BUSES, VANS AND LIMOUSINES

(COLUMN D)

(COLUMN C)

Subtract:

(A) The number of vehicles on Line 1 in Column C above that has a vehicle capacity of 10 or less

passengers, including the driver.

(B) (Optional)The number of vehicles on Line 1 in Column A above that are used exclusively in

(

)

intrastate transportation. You are required to maintain a list of vehicles excluded under this

option. See Instructions for additional requirements if you select this option.

(Optional) Add a number of vehicles not shown on Line 1 above that are:

(A) Commercial motor vehicles operating exclusively in intrastate commerce. (See instructions for

definition of commercial motor vehicle.)

(B) Used in commerce to transport passengers or property for compensation and have a GVWR or

GVW of 10,000 lbs or less, or a passenger capacity of 10 or less, including the driver.

Total Number of Vehicles (Line 1 minus Line 2 plus Line 3)

SECTION 5. FEE TABLE

Number of

Number of Vehicles

Amount Due

Number of Vehicles

Amount Due

Vehicles

$76

$452

0-2

6-20

101-1000

$7,511

3-5

$227

21-100

$1,576

1001 or more

$73,346

SECTION 6. FEES DUE – MOTOR CARRIER & MOTOR PRIVATE CARRIER

Using the number of vehicles in Section 4, Line 4 above, enter the Amount Due from the table above.

SECTION 7. CERTIFICATION

I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute and file

this document on behalf of the applicant. (Penalty provisions subject to the laws of the registration state.)

Date

Name Of Owner Or Authorized Representative (Printed)

Title

Signature

Form Mv-Iucr - Unified Carrier Registration Form

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