Irp Form T-139 - Georgia Irp Mileage Schedule A Page 2

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IRP Vehicle Schedule A Form T-138 (Continued) - (Rev. 4/2013)

Page 2 of 4

Section 3 Vehicle Detail - Complete Form T-138A if space for more vehicles is needed.

(1) Unit/

(2) Vehicle Identification #

(3) #

(4)

(5)

(6)

(7)

(8) Owner’s Name

(9) GA Title#

(10)

(11)

(12)

(13)

Equip. #

of Axles

Empty

Com-

Vehicle’s

Factory

Short

Carrier’s

Safety

or Seats

Weight

bined

Purchase

List

Term

TIN#

USDOT#

Change

Gross

Price

Lease

Vehicle Level

(Y/N)

Vehicle

Weight

(Y/N)

Column 13- Will the control and responsibility for the safety of this vehicle be assigned to a different Motor Carrier during the registration year?

SECTION 4 Certification & Signature

(1)

Under penalty of perjury, I hereby certify that I am the Registrant/Carrier or I am authorized to sign for the above named Registrant/Carrier. I further certify that the

information shown on this form and all attachments is complete and correct

Signature:

Printed Name:

Position or Job Title:

Date: