Change Of Company Information Form - Kentucky Transportation Cabinet
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1TC 95-573
Kentucky Transportation Cabinet
11/2011
Division of Motor Carriers
CHANGE OF COMPANY INFORMATION
Office Use Only
MAIL TO:
Initial and pass to next section.
PO Box 2004, Frankfort KY 40602-2004
Phone: (502) 564-1257 Fax: (502) 696-3900 8:00 am – 4:30 pm EST
Tax Branch
Walk-ins: 8:00 am – 4:00 pm EST
Credentials
IRP
OW/OD
COMPANY NAME: _______________________________________________________________________________ (REQUIRED)
List all numbers that you currently have. Enter leading zeros. If multiple numbers, please list separately on another sheet.
KIT#:
KYU#:
IRP#:
_____________________________
__________________________
_____________________________
IFTA#:
USDOT#:
_______________________________________________________
_________________________________
Enter states initial and leading zeros.
KY Intrastate for Hire#:
KY Interstate Exempt for Hire#:
___________________________
___________________________
(
VERIFICATION OF INSURANCE (FORM E) MUST BE SUBMITTED PRIOR TO THIS AGENCY PROCESSING A NAME CHANGE FOR THE KENTUCKY FOR HIRE AUTHORITIES)
NOTICE:
NAME CHANGE REQUEST WILL NOT BE PROCESSED UNTIL THE MOTOR CARRIER HAS UPDATED THEIR U.S. DOT
NUMBER TO REFLECT THE NEW NAME.
CONTACT YOUR BASE STATE FOR THE U.S. DOT MOTOR CARRIER
IDENTIFICATION REPORT, FORM 150, (INDICATE ‘UPDATE’ FOR THE REASON OF FILING. YOU MAY OBTAIN THIS FORM
FROM THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION’S (FMCSA) WEBSITE:
PREVIOUS FEIN#: ________________________________ NEW FEIN#: (IF APPLICABLE) ________________________________
PREVIOUS LEGAL NAME: _____________________________________________________________________________________
NEW LEGAL NAME: __________________________________________________________________________________________
PREVIOUS D/B/A: ____________________________________________________________________________________________
NEW D/B/A: _________________________________________________________________________________________________
(MOTOR CARRIERS THAT ARE REQUIRED TO MAINTAIN A BOND MUST SUBMIT A BOND RIDER)
PHYSICAL ADDRESS: ________________________________________________________________________________________
CITY: ______________________________________________________ STATE: _____________ ZIP: ______________________
MAILING ADDRESS: __________________________________________________________________________________________
CITY: ______________________________________________________ STATE: _____________ ZIP: _______________________
PHONE: ______________________________________________ FAX: _______________________________________________
CONTACT PERSON: _________________________________________________________________________________________
E-MAIL: ___________________________________________________________________________________________________
Signature:
Date:
_______________________________________________________
_______________________________
Note:
Web filers (tax, permits, IRP etc.) please keep a current e-mail address on file for quarterly reminders and updates.
If using overnight delivery services, please send to: Division of Motor Carriers, 200 Mero Street, Frankfort, KY 40622
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