Form Mfut-12 - Application For Motor Fuel Use Tax Ifta License And Decals

Step 5: Identify your type of operation

Check your type of business ownership.

____ Individual

____ Corporation

____ Partnership

____ State/federal government

____ Non-profit organization

If you checked “Corporation,” write the date and state of incorporation.

__ __/__ __/__ __ __ __

______________

Month

Day

Year

State

List the owners or corporate officers.

Social Security no.

Name and title

City and state

_ _ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________

Do you currently have or have you ever had an IFTA license from a state other than Illinois?

____ yes

____ no

If you checked “yes,” tell us in what jurisdictions you were previously licensed. ____________________________________

Step 6: Tell us your fuel types, operations, and bulk fuel storage

Check the type of fuels used in the qualified motor vehicles you own or operate.

____ Diesel

____ Gasoline

____ Gasohol

____ Liquefied petroleum gas

____ Compressed natural gas

Check each jurisdiction in which you may operate (OP) as a carrier and where you maintain bulk fuel (BF) storage.

OP BF

___ ___ IL - Illinois

___ ___ KS - Kansas

___ ___ NJ - New Jersey

___ ___ VT - Vermont

___ ___ AK - Alaska

___ ___ KY - Kentucky

___ ___ NM - New Mexico

___ ___ WA - Washington

___ ___ AL - Alabama

___ ___ LA - Louisiana

___ ___ NV - Nevada

___ ___ WI - Wisconsin

___ ___ AR - Arkansas

___ ___ MA - Massachusetts

___ ___ NY - New York

___ ___ WV - West Virginia

___ ___ AZ - Arizona

___ ___ MD - Maryland

___ ___ OH - Ohio

___ ___ WY - Wyoming

___ ___ CA - California

___ ___ ME - Maine

___ ___ OK - Oklahoma

Canadian Provinces

___ ___ CO - Colorado

___ ___ MI - Michigan

___ ___ OR - Oregon

___ ___ AB - Alberta

___ ___ CT - Connecticut

___ ___ MN - Minnesota

___ ___ PA - Pennsylvania

___ ___ BC -

British Columbia

___ ___ DC - Dist. of Columbia ___ ___ MO - Missouri

___ ___ RI - Rhode Island ___ ___ MB - Manitoba

___ ___ DE - Delaware

___ ___ MS - Mississippi

___ ___ SC - South Carolina ___ ___ NB - New Brunswick

___ ___ FL - Florida

___ ___ MT - Montana

___ ___ SD - South Dakota ___ ___ NS - Nova Scotia

___ ___ GA - Georgia

___ ___ NC - North Carolina

___ ___ TN - Tennessee

___ ___ ON - Ontario

___ ___ IA - Iowa

___ ___ ND - North Dakota

___ ___ TX - Texas

___ ___ PE - Prince Edward

___ ___ ID - Idaho

___ ___ NE - Nebraska

___ ___ UT - Utah

___ ___ PQ - Quebec

___ ___ IN - Indiana

___ ___ NH - New Hampshire ___ ___ VA - Virginia

___ ___ SK - Saskatchewan

___ ___ ________________

Step 7: 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 application and, to the best of my knowledge, it is true, correct, and complete. I

accept personal responsibility for license display, record keeping, reporting, and payment requirements as specified in the Illinois Motor Fuel

Tax Law and the International Fuel Tax Agreement. I further agree that the Illinois Department of Revenue may withhold any overpayments

due me if I am delinquent on payments of motor fuel use taxes due the state of Illinois or any IFTA member jurisdiction. I understand that

failure to comply with these provisions is grounds for revocation of my license in all applicable jurisdictions.

Note: Without proper signature from an owner, partner, authorized corporate officer, authorized agent, or employee who has the control,

supervision, or responsibility of filing returns and making payment of the tax, your application will be denied.

__________________________________________________

Mail to: MOTOR FUEL USE TAX SECTION

Signature

ILLINOIS DEPARTMENT OF REVENUE

__________________________________________________

PO BOX 19467

Title

SPRINGFIELD IL 62794-9467

_____________________________________

___________

Telephone

Date

217 785-1397

MFUT-12 Back (R-8/99)

Form Mfut-12 - Application For Motor Fuel Use Tax Ifta License And Decals - 1999 Page 2

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