Unified Carrier Registration - South Dakota Department Of Revenue

UNIFIED CARRIER REGISTRATION -Year 2012

DEPARTMENT OF REVENUE

To register online go to

445 E CAPITOL AVE

PIERRE SD 57501

SECTION 1. GENERAL INFORMATION

USDOT Number

MC or MX Number

FF Number

Telephone Number

Fax Number

Legal Name

E-Mail Address

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. Payment from out-of-state businesses must be in the form of a Cashiers Check or Money Order made payable to South Dakota

Department of Revenue & Regulation and go to Section 7.

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

Check only one box:

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

The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30, 2011.

NUMBER OF MOTOR COACHES,

NUMBER OF STRAIGHT TRUCKS

SCHOOL BUSES, MINI-BUSES, VANS

TOTAL

AND TRACTORS

(COLUMN B)

AND LIMOUSINES

(COLUMN D)

(COLUMN A)

(COLUMN C)

1. Subtract:

a. The number of vehicles in Column C above that has a vehicle capacity of 10 or less passengers, including the driver.

b. (Optional) The number of vehicles in Column A that is used only in intrastate commerce. ……………………. (

)

2. (Optional) Add a number of vehicles not shown above that are:

a. Commercial motor vehicles operating solely in intrastate commerce. (See instructions for the 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 driver…………………………………………………………………….

3. Total Number of Vehicles (TOTAL (COLUMN D) minus LINE 1 plus LINE 2). . . . . . . . . . . . . . . . . . . . . . . . . . _____________

SECTION 5. FEE TABLE

Number of Vehicles Amount Due

Number of Vehicles

Amount Due

Number of Vehicles

Amount Due

$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 3 above, enter the Amount Due from the table above.

NOTE: CERTIFIED CHECK OR MONEY ORDER IS REQUIRED FOR OUT-OF-STATE CARRIERS. MAKE

CHECKS PAYABLE TO SOUTH DAKOTA DEPARTMENT OF REVENUE & REGULATION.

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

Unified Carrier Registration - South Dakota Department Of Revenue - 2012

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