Fillable Mv Irp-B - Mileage Schelude Template printable pdf download

Mv Irp-B - Mileage Schelude Template

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DEPARTMENT USE ONLY

Effective

Date __________________

Initials _________________

MV IRP-B (1/17)

INSTRUCTIONS ON REVERSE SIDE

Renewal Mo/License Yr.

Account Number

Fleet Number

Email Address

Registrant Name

DBA Name

Contact Person

Business Address

Telephone Number

Within City Limits

( )

Outside City Limits

City

State

Zip

Fax Number

( )

US DOT Number

Taxpayer Identification Number

Type of Operation (Check One)

Commodity Class (Check One)

For Hire Exempt

For Hire

All

Logs

Mailing Address

Contract Carrier

For Hire Rental

Exempt

Passengers

City

State

Zip

Private

Common Carrier

Household Goods

List mileage accrued in each jurisdiction in which the fleet traveled during the period 07/01/____ through 06/30/____.

If this is a new operation, please attach a Schedule G.

“X”

JURISDICTION

MILEAGE

“X”

JURISDICTION

MILEAGE

“X”

JURISDICTION

MILEAGE

AL–ALABAMA

Ml–MICHIGAN

TX–TEXAS

AK–ALASKA

MN–MINNESOTA

UT–UTAH

AR–ARKANSAS

MO–MISSOURI

VA–VIRGINIA

AZ–ARIZONA

MS–MISSISSIPPI

VT–VERMONT

CA–CALIFORNIA

MT–MONTANA

WA–WASHINGTON

CO–COLORADO

NC–NORTH CAROLINA

WI–WISCONSIN

CT–CONNECTICUT

ND–NORTH DAKOTA

WV–WEST VIRGINIA

DC–DIST. COLUMBIA

NE–NEBRASKA

WY–WYOMING

DE–DELAWARE

NH–NEW HAMPSHIRE

AB–ALBERTA

FL–FLORIDA

NJ–NEW JERSEY

BC–BRIT. COLUMBIA

GA–GEORGIA

NM–NEW MEXICO

MB–MANITOBA

IA–IOWA

NV–NEVADA

NB–NEW BRUNSWICK

ID–IDAHO

NY–NEW YORK

NF–NEWFOUNDLAND

IL–ILLINOIS

OH–OHIO

NS–NOVA SCOTIA

IN–INDIANA

OK–OKLAHOMA

NT–N W TERRITORY

KS–KANSAS

OR–OREGON

ON–ONTARIO

KY–KENTUCKY

PA–PENNSYLVANIA

PE–PRINCE ED. IS.

LA–LOUISIANA

RI–RHODE ISLAND

QC–QUEBEC

MA–MASSACHUSETTS

SC–SOUTH CAROLINA

SK–SASKATCHEWAN

MD–MARYLAND

SD–SOUTH DAKOTA

YT–YUKON TERR.

ME–MAINE

TN–TENNESSEE

MX–MEXICO

TOTAL MILES

I affirm under oath that the information contained in this application is true and correct and by signing this application, I am aware of the International Registration Plan Record Keeping Requirements.

*By:_________________________________________________________ Title: _________________________________ Date: __________________________

*must be an owner, partner, corporate officer, or hold power of attorney for the registrant.