Form Mfut-12-R - Motor Fuel Use Tax
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Illinois Department of Revenue
MFUT-12-R Motor Fuel Use Tax
IFTA Replacement Decal Order
Do not write above this line.
Read this information first.
This form may only be used to order decals to replace those that were lost, stolen, damaged, etc. We will mail your replacement
decals to the address you provided on Form MFUT-12, Application for Motor Fuel Use Tax IFTA License and Decals. If you need
to update this address or any other information you originally provided on Form MFUT-12, contact us weekdays during normal
business hours at 217 785-1397. Please type or print in ink.
2
0 __ __
Step 1: Tell us the year for which you are ordering decals: December 31,
Step 2: Identify your business
1
2
FEIN
______________________________________
IFTA Account ID:________________________________
Federal employer identification number or Social Security number
SSN
3
4
Legal business name:_____________________________
Trade (DBA) name: ______________________________
Step 3: Complete your replacement decal order
You must purchase and display one set (two decals) for each of your qualified motor vehicles. There is a $2.00 cost per decal set.
5
My original decal was: ___ Lost ___ Stolen ___ Damaged ___ Other. Explain: ___________________________________
6
My original decal serial number was _________________
(Attach additional sheet if multiple decals are being replaced.)
To figure how much you owe, multiply the number of decal sets by 2.00. This is your cost for replacement decals.
2.00
7
Total number of replacement decal sets needed: ___________
X
=
$_______________
0.00
Make your check payable to “Illinois Department of Revenue.”
Step 4: Sign below
Your FEIN or SSN is used for account identification, payment processing, and record keeping. Your number and pertinent account information
may be provided to IFTA jurisdictions, governmental and state agencies, and any persons necessary for administering the Motor Fuel Tax Law.
Under penalties of perjury, I state that I have examined this replacement decal order and, to the best of my knowledge, it is true, correct, and complete.
_________________________________________________
Printed name
_________________________________________________
Signature
_______________________
Title
(_____) _____ - _________
__ __/__ __/__ __ __ __
Telephone
Month
Day
Year
Step 5: Mail Form MFUT-12-R and payment to:
MOTOR FUEL USE TAX SECTION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19467
SPRINGFIELD IL 62794-9467
Telephone: 217 785-1397
*909601110*
This form is authorized by the Illinois Motor Fuel Tax Law. Disclosure of this information is REQUIRED. Failure to provide
MFUT-12-R
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-3262
N-05/09)
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