Form Tmt-1.2 - Renewal Application For Highway Use Tax And/or Automotive Fuel Carrier Premits 19th Series

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HUT Count:
AFC Count:
Highway Use Tax Renewal Unit
Total permits:
W A Harriman Campus
Albany NY 12227
Renewal Application for Highway Use Tax and/or
Automotive Fuel Carrier Permits - 19th Series
For office use only
Number
SR
PO
Address
SUSP
Total fee
of permits
HUT
AFC
Name
DELQ
NR
PC
$
ID #
ASMT
CANC
REV
Deposit number
Underpaid
Overpaid
No remit
Late
Refund amount
$
1. Taxpayer identification number
2. U.S. DOT number
3. IFTA base jurisdiction
4. Mailing address for permits (if different from above preprinted address)
5. Business telephone number
City
State
ZIP code
(
)
6. Office where records are available: street address
City
County
State
ZIP code
Name of representative or agent
Telephone number
(
)
7. Names, titles, and addresses of principal officers of corporation, or of partners, members of LLC/LLP, owners, etc. (attach additional sheets if necessary)
Social security number
City or town, state and ZIP code
Name
Title
Address (number and street)
.
8
For all leased vehicles, list the manufacturer's serial number, owner's name, federal employer ID number (FEIN) or social security number (SSN), and address
(attach additional sheets if necessary)
Owner's federal
Mark an X:
Manufacturer's
employer ID or social
serial
FEIN
SSN
security number
number
Owner's name
Owner's home address
9. I hereby declare that the statements contained in this application are true, correct, and complete, and have been made with the knowledge that a willfully false
representation is a crime under section 1815 of the Tax Law and sections 175.35 and 210.45 of the Penal Law, punishable by fines and penalties stipulated
therein.
Signature
Title
Date
Submit with this application renewal permit fees of $4 for each self-propelled vehicle and $2 for each trailer,
Return this application to:
semitrailer, or other attached device(s) that transports automotive fuel. Applications received after
December 31, 2005, are late and subject to fees of $15/$5. The 19th series permits and stickers must be in
NYS Tax Department
use and displayed on and after April 1, 2006. Make remittance payable to Commissioner of Taxation and
TSRD - HUT Renewal Unit
Finance. Renewal permits and stickers will be sent to you after approval of this application.
W A Harriman Campus
Albany NY 12227-0163
TMT-1.2
(10/05)

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