Form Mfut-12 - Motor Fuel Use Tax Ifta License And Decals Application - 2010
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Illinois Department of Revenue
MFUT-12
Motor Fuel Use Tax
IFTA License and Decals Application
Step 1: Provide your business’ identifi cation numbers
Identify your application year:
1
FEIN
______________________________________
2 0
or
December 31,
__ __
Federal employer identifi cation number
Social Security number
SSN
2
IFTA Account ID: _________________________________
3
4
IRP no.: _______________________________________
US DOT no.:____________________________________
Illinois international registration plan fi rm no. issued by the Illinois Secretary of State
United States Department of Transportation number
Step 2: Provide application information
5
Check the type of this application: ___ Original ___ Renewal ___ Additional decals ___ Correcting account information
6
If you currently have an IFTA license other than from Illinois provide that jurisdiction: ______________________________
7
If you have ever had an IFTA license other than from Illinois provide that jurisdiction: ______________________________
Step 3: Identify your business
8
Write your business’ name and address. A physical address is required. Post Offi ce box numbers will not be accepted.
Legal name: ____________________________________
Trade (DBA) name: __________________________________
Street address:__ ____________________________________________________________________________________
Number and street (required)
________________________________________________________________________________________________
City
State
ZIP
Country
Contact person: _________________________________
Business phone: (_____)______ - ___________
Title: ________ _________________________________
Cell phone:
(_____)______ - ___________
9
Write the name and mailing address where you want your tax returns sent (if different than Line 8). If the name is different
than Line 8, a power of attorney form must also be attached.
Name: ___________________________________________Email:_____________________________________________
Mailing address:________________________________________________________ Fax: (_____)______ - ___________
Number and street (required)
________________________________________________________________________________________________
City
State
ZIP
Country
10
Write the name and mailing address where you want your decals sent (if different than Line 8).
Name: ____________________________________________________________________________________________
Mailing address:_____________________________________________________________________________________
Number and street are required. Post offi ce boxes cannot be accepted.
________________________________________________________________________________________________
City
State
ZIP
Country
11
Check your type of business ownership.
____ Individual
____ Corporation
____ Partnership
____ State/federal government
____ Non-profi t organization
12
If you checked “Corporation,” write the date and state of incorporation.
__ __/__ __/__ __ __ __
______________
Month
Day
Year
State
13
List the owners, partners, or corporate offi cers.
Social Security no.
Name and title
City and State
_ _ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________
_ _ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________
_ _ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________
_ _ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________
*909501110*
MFUT-12 (R-10/10)
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Parent category: Financial