Form Ifta-200a - New Account Application For Motor Carrier Road Tax/ifta Decals - 2015 Page 2
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1
2SECTION F.
BUSINESS ORGANIZATION INFORMATION
Check the box that describes the organization of your business.
Corporation
Partnership
Sole Proprietorship
Limited Liability Company
Limited Partnership
Provide the information requested below of all individual owners and elected officers constituting the ownership, partnership, association or corporation.
Attach additional pages if needed.
Name
Title
SSN
Home Address
City
State
ZIP Code
Name
Title
SSN
Home Address
City
State
ZIP Code
Name, title, telephone and email address of persons (other than individual owners, partners or elected officers of the partnership, association, or
corporation) who are authorized by any individual listed above, or by power of attorney, to sign and/or discuss with the department any information
related to IFTA reports.
Name
Title
Email Address
Telephone Number
Name
Title
Email Address
Telephone Number
Name
Title
Email Address
Telephone Number
SECTION G.
BULK STORAGE
Do you maintain bulk fuel storage for highway use?
Yes
No
If yes, indicate the fuel type and the jurisdiction where the bulk fuel is stored.
FUEL TYPE
JURISDICTION
FUEL TYPE
JURISDICTION
FUEL TYPE
JURISDICTION
FUEL TYPE
JURISDICTION
FUEL TYPE
JURISDICTION
FUEL TYPE
JURISDICTION
SECTION H.
MISCELLANEOUS
Have you ever been issued decals in another jurisdiction?
Yes
No
If yes, specify jurisdiction?
Is the license currently suspended or revoked?
Yes
No
Do you currently operate any dual-fuel qualified motor vehicles?
Yes
No
If yes, how many?
Check the applicable box(es) to indicate the type of product you will be using:
Diesel
Gasoline/Gasohol
LNG
LP Gas
CNG
Other
Identify the type of vehicle operation by checking the appropriate block:
Common Carrier
Contract Carrier
Carrier For Hire
Private Carrier
SECTION I.
CERTIFICATION
ALL APPLICANTS MUST COMPLETE THIS SECTION
Applicant purchasing International Fuel Tax Agreement (IFTA) decals agrees to comply with tax reporting, payment, recordkeeping, and license display requirements
as specified in the motor carrier road tax (MCRT) statutes and/or the International Fuel Tax Agreement. Applicant further agrees that Pennsylvania may withhold
any refunds due if applicant is delinquent on payment of fuel taxes due any member jurisdiction. Failure to comply with these provisions shall be grounds for
revocation of license in all member jurisdictions.
Applicant purchasing PA MCRT decals attests that all travel by its qualified motor vehicles is within Pennsylvania, except operations conducted under a valid fuel
trip permit, and that all fuel used in such operations is Pennsylvania tax-paid fuel.
Applicant further agrees, under penalty of perjury, that the information provided on this application, to the best of his/her knowledge, is true, accurate and complete.
This form must be signed by an owner, partner or corporate officer named on this application or by an authorized agent. If signed by an authorized agent, a
properly completed Power of Attorney and Declaration of Representative (REV-677) must be attached to this application.
Name
Signature
Title
Date
Please sign after printing.
Bureau of Motor and Alternative Fuel Taxes
Reset Entire Form
PRINT FORM
PO Box 280646 Harrisburg, PA 17128 800.482.4382 F 717.787.6261
Return to page one.
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