Form Irp-5-Schedule B Mileage Information

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New York State Department of Motor Vehicles
IRP-5 (4/09)
DMV USE ONLY
INTERNATIONAL REGISTRATION PLAN
SCHEDULE B MILEAGE INFORMATION
SUPP#: __________________
31. REG YEAR: __________ 32. ACCOUNT #:__________________ 33. FLEET #:_________ 34. CARRIER ________________________________
(35)
(36)
(37)
PRORATE?
STATE
ACTUAL
ESTIMATED
PRORATE?
STATE
ACTUAL
ESTIMATED
Yes/No
MILEAGE
MILEAGE
Yes/No
MILEAGE
MILEAGE
AK (Alaska)
NV (Nevada)
AL (Alabama)
NY (New York)
AR (Arkansas)
OH (Ohio)
AZ (Arizona)
OK (Oklahoma)
CA (California)
OR (Oregon)
CO (Colorado)
PA (Pennsylvania)
CT (Connecticut)
RI (Rhode Island)
DC (Dist. of Col.)
SC (South Carolina)
DE (Delaware)
SD (South Dakota)
FL (Florida)
TN (Tennessee)
GA (Georgia)
TX (Texas)
IA (Iowa)
UT (Utah)
ID (Idaho)
VA (Virginia)
IL (Illinois)
VT (Vermont)
IN (Indiana)
WA (Washington)
KS (Kansas)
WI (Wisconsin)
KY (Kentucky)
WV (West Virginia)
LA (Louisiana)
WY (Wyoming)
MA (Massachusetts)
MX (Mexico)
MD (Maryland)
CANADA
ME (Maine)
AB (Alberta)
MI (Michigan)
BC (British Columbia)
MN (Minnesota)
MB (Manitoba)
MO (Missouri)
NB (New Brunswick)
NL (Newfoundland/
MS (Mississippi)
Labrador)
MT (Montana)
NS (Nova Scotia)
NC (North Carolina)
NT (Northwest Terr.)
ND (North Dakota)
ON (Ontario)
NE (Nebraska)
PE (Prince Edward Isl.)
NH (New Hampshire)
QC (Quebec)
NJ (New Jersey)
SK (Saskatchewan)
NM (New Mexico)
YT (Yukon)
0
0
38. ESTIMATED MILEAGE:_____________
39. ACTUAL MILEAGE:_____________
40. TOTAL OF ALL MILEAGE: _______________
41. NOTE: For any Estimated Mileage shown above, you must explain why you are using estimated mileage. This explanation needs to include
information such as business purposes, contracts, number of anticipated trips and route information (a separate sheet of paper may be used if
necessary).
CERTIFICATION: I certify that the information provided on this mileage schedule is true and correct. I certify that the actual distance reported on this
form is supported by my distance records and they must be maintained in compliance with IRP recordkeeping requirements and retained for 6 years from
the trip date. I understand that my distance records are subject to audit any time and will make these records available. I will pay all auditor travel expenses
if my distance records cannot be made available. I understand that additional fees will be assessed and/or my IRP account will be suspended or canceled
if my distance records are not made available and/or I do not comply with IRP Requirements.
±
Signature
TITLE: (If signing for a corporation)
Date
(President, Vice-President, Secretary, Treasurer, or Comptroller. Anyone
.)
PAGE 1 0F 2
else signing for a corporation must send in an original Power of Attorney
reset/clear

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