Form 2823 - Michigan Ifta Fuel Tax License Application
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License Year
Michigan Department of Treasury
2823 (Rev. 10-09)
1.
Michigan IFTA Fuel Tax License Application
Issued under P.A. 119 of 1980, as amended.
2.
Federal Employer Identification Number (FEIN or TR Number)
INSTRUCTIONS: Read attached instructions before completing this application.
When applying for additional decals complete only items 1, 2, 3, 6 and 17, plus
3.
sign and date. Allow 30 days for processing.
Social Security Number
4.
5.
U.S. DOT Number
IRP Number
b. Additional Decals
a. New
6.
Contact Person
Complete Company or Individual Name (include, if applicable, Corp., Inc., P.C., L.L.C., etc.)
7.
Business Telephone
Business Name, Assumed Name or DBA (if used)
Home Telephone
Address (Number and Street or RR)
8.
In what month and year did you begin doing business in Michigan?
City, State, ZIP Code
Country
9.
10.
Is your IFTA license currently revoked?
Do you maintain bulk fuel storage in Michigan?
a.
Yes
No
Yes
No
b.
If yes, list the jurisdictions below in which
If Yes to part a, what is the storage capacity in gallons? ___________________________ gallons
your license is revoked.
c.
List locations of all storage tanks.
11a.
Do you operate part of the year?
Do you maintain bulk fuel storage in other IFTA jurisdictions?
Yes
No
d.
Yes
No
If yes, list the jurisdictions below.
11b.
If Yes, list months of operation below.
12.
Type of Business Ownership (check one only)
5. Limited Liability Company
4. Limited Liability
6. Non-Profit
1. Individual
2. Partnership
3. Corporation
Partnership
7. Government
8. Religious
9. Other
13.
Physical address if different than address listed in item 6. This is the actual location of the business. Enter complete address.
Address (Number and Street, or RR)
City
State
ZIP Code
Country
14.
What type(s) of fuel are used in the vehicle(s) in your fleet? (Check all that apply):
a. A-55
b. E-85
c. M-85
d. Methanol
e. LNG
k. Gasohol
i. Biodiesel
f. Diesel
g. Gasoline
h. Propane
i. CNG
j. Ethanol
15.
In which jurisdictions do you operate motor vehicles? (Check all that apply):
Canadian Provinces
Illinois
1.
Montana
Rhode Island
Alabama
14.
27.
40.
52.
Alberta
Indiana
2.
North Carolina
South Carolina
41.
53.
British Columbia
15.
28.
Iowa
3.
North Dakota
South Dakota
Arkansas
16.
29.
42.
54.
Manitoba
Kansas
4.
Nebraska
Tennessee
Arizona
17.
30.
43.
55.
New Brunswick
Kentucky
5.
Nevada
Texas
California
18.
31.
44.
56.
Newfoundland
Louisiana
Utah
6.
New Hampshire
Colorado
19.
32.
45.
57.
Northwest Territories
Maine
7.
New Jersey
Vermont
Connecticut
20.
33.
46.
58.
Nova Scotia
Maryland
8.
New Mexico
Virginia
Delaware
21.
34.
47.
59.
Ontario
Massachusetts
9.
New York
Washington
Dist. of Columbia
22.
35.
48.
60.
Prince Edward Island
Michigan
10.
Ohio
West Virginia
49.
61.
Quebec
Florida
23.
36.
Minnesota
11.
Oklahoma
Wisconsin
Georgia
24.
37.
50.
62.
Saskatchewan
Mississippi
12.
Oregon
Wyoming
25.
38.
51.
63.
Yukon Territory
Missouri
13.
Pennsylvania
Idaho
26.
39.
16a.
Are your vehicles involved in a lease agreement?
a. Yes
b. No
b.
If yes, who is responsible for reporting all operations?
a. Lessor
b. Lessee
Enter address information for lessor and lessee in items 23a and
23b on the reverse side of this form.
17. Number of IFTA decal sets you will need
for your "Qualifying Vehicles" (Please see instructions):
________________________
These decals are serialized and you are accountable for the numbers issued to your account. These decals are not transferable under a penalty of law.
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