Form Ifta-200a - New Account Application For Motor Carrier Road Tax/ifta Decals - 2015
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2IFTA-200A (3-15)
New Account
BUREAU USE ONLY
Application for
BUREAU OF MOTOR AND
Motor Carrier Road
ALTERNATIVE FUEL TAXES
PO BOX 280646
Tax/IFTA Decals
HARRISBURG PA 17128-0646
SECTION A.
APPLICANT INFORMATION
Start
Legal Name (Individual applicants should provide full legal name.)
FEIN (If unavailable, Social Security Number)
Trade Name or DBA if different from Legal Name
US DOT Number
Contact Person Name
Telephone Number
Fax Number
Contact Person Title
Contact Person Email Address
SECTION B.
ADDRESS INFORMATION
Physical Street Address (PO BOX is not acceptable)
Telephone Number
County
City
State
ZIP Code
Mailing Address (if different from above)
Telephone Number
County
City
State
ZIP Code
SECTION C.
TAX REPORTING SERVICE
Company Name
Contact Person
Contact Person Title
Address
Telephone Number
County
City
State
ZIP Code
SECTION D.
EXEMPTIONS
Are you requesting IFTA decals for vehicles registered as any of the following? If yes, please include form IFTA-200W with
this application.
A qualified motor vehicle bearing a Pennsylvania farm vehicle registration plate and operated in accordance with the
Yes
No
restrictions of Title 75 Pa.C.S. § 1344 (relating to use of farm vehicle plates)
A qualified motor vehicle exempt from registration as a farm vehicle and operated in accordance with the restrictions of
Yes
No
Title 75 Pa.C.S. § 1302(10)
An emergency vehicle as defined by Title 75 Pa.C.S. § 102 (relating to definitions)
Yes
No
A vehicle operated by the commonwealth, its political subdivisions, the federal government or its agencies, any foreign
country, or any state or political subdivision that grants similar exceptions to publicly owned vehicles registered in this
Yes
No
commonwealth
A school bus
Yes
No
A motorbus owned by and registered to a church
Yes
No
An implement of husbandry or commercial implement of husbandry as defined by Title 75 Pa.C.S. § 102 (relating to definitions)
Yes
No
Special mobile equipment as defined by Title 75 Pa.C.S. § 102 (relating to definitions)
Yes
No
SECTION E.
DECALS
Complete the following for each qualified motor vehicle you intend to operate.
Decal year requested:
Indicate decal year requested
Mail this request and your check or money order to:
IFTA Decals:
PA DEPARTMENT OF REVENUE
Number of vehicles that travel in PA and out-of-state
BUREAU OF MOTOR AND ALTERNATIVE FUEL TAXES
PO BOX 280646
PA MCRT Decals:
HARRISBURG PA 17128-0646
Number of vehicles that travel in PA exclusively
Total Decals requested:
Add IFTA and PA MCRT decals requested
Total Due:
Check or money orders payable to PA Department of Revenue.
x $12/set = $
Multiply total decals requested by $12
DO NOT send cash.
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