Special Fuel Users Decal-Maine Only Application Form

MAINE OPERATION ONLY

MAINE OPERATION ONLY

MAINE OPERATION ONLY

MAINE OPERATION ONLY

STATE OF MAINE

SPECIAL FUEL USER’S DECAL APPLICATION

Motor Carrier Services, Fuel Unit, 29 SHS, Augusta, ME 04333-0029

Tel: (207) 624-9000 Ext. 52137

TTY Users call Maine relay 711

PLEASE CHECK ONE

:

NEW APPLICANT

ADDITIONAL DECAL(S)

***

***

For a RENEWAL Application, please call the Fuel Unit at (207) 624-9000, Ext. 52137

Federal ID/SSN or Social Insurance (Required)

DOT Number (Required)

_____________________________________

_____________________________________

Legal Name (If not Incorporated, YOUR name)

Doing Business As (DBA)

_____________________________________

_____________________________________

Mailing Address

Telephone Number (Required)

_____________________________________

_____________________________________________

City

State

Zip

Physical Location (No PO Box #’s)

_______________________________________________________

________________________________________________________

E-mail address (if any)

City / Town

State

Zip

______________________________________________________________________________________________________________________________________________________

Type of Ownership: Individual

Partnership

Corporation

LLC

Other

_________________________

Type of Vehicles:

Trucks

Buses

(Dealer plated vehicles do not require decals in Maine)

Do you lease vehicles?

Yes

No

If yes,

From others

To others

$5.00

Number of Decals (1decal per vehicle) _____________ X

= ______________

Please make checks payable to: SECRETARY OF STATE

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Upon filing this application with the State of Maine, you are exempt from filing fuel tax returns, except if you previously had an IFTA account.

You must file all returns, pay any owed taxes, and close the IFTA account. Contact the IFTA Unit for additional information. If at any time

during the tax year your status should change, you need to notify this office and file the necessary returns. I declare under penalty of false

statement, that to the best of my knowledge and belief, the statements contained herein are true and correct.

Signature (Required)

Title

Date

Disclosure:

This statement is made in accordance with the Federal Privacy Act of 1974, Section 7(b). Providing your Social Security Number (SSN) or

Federal Employer Identification Number (FEIN) is mandatory and is required by State and Federal law or rule to receive Motor Carrier

credentials. Your SSN or FEIN will be used solely for identification purposes and will be kept confidential.

_____

FOR OFFICE USE ONLY:

FROM _____________

TO _______________ INTLS ________

REEL: ___

___

CC AUTH #_______________ CHECK# ____________ MO# ______________ CASH ________

FRAME: ___________

VS Status: __________

DOT: __________

UCR: ___________

CORP: _________

Lic-Decals Issued: __________

)

(Active–In Good Standing)

(If applicable

Revised 7/09/2012