Form Pt-95 - Request For Apportionment Of Ad Valorem Assessment On Vehicles Engaged In Interstate Commerce
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1PT-95
GA DEPARTMENT OF REVENUE
LOCAL GOVERNMENT SERVICES
DIVISION
REQUEST FOR APPORTIONMENT OF AD VALOREM ASSESSMENT
ON VEHICLES ENGAGED IN INTERSTATE COMMERCE
____________________________
__________
COUNTY:
YEAR:
B: VEHICLE
A: TAXPAYER/APPLICANT
YEAR:
OWNER:
MAKE:
ADDRESS:
MODEL:
VIN:
CITY:
STATE:
ZIP:
C: MILEAGE OUTSIDE GEORGIA
Indicate if mileage listed will be for this vehicle or for a fleet: [ ] V [
] F (Note: Tax Commissioner may require individual mileage)
JURISDICTION
MILEAGE ALLOWED
JURISDICTION
MILEAGE ALLOWED
JURISDICTION
MILEAGE ALLOWED
Alaska
Louisiana
Ohio
Alabama
Massachusetts
Oklahoma
Arkansas
Maryland
Oregon
Arizona
Maine
Pennsylvania
California
Michigan
Rhode Island
Colorado
Minnesota
South Carolina
Connecticut
Missouri
South Dakota
Tennessee
District of Columbia
Mississippi
Texas
Delaware
Montana
Utah
Florida
North Carolina
Hawaii
North Dakota
Virginia
Iowa
Nebraska
Vermont
Idaho
New Hampshire
Washington
Illinois
New Jersey
Wisconsin
Indiana
New Mexico
West Virginia
Kansas
Nevada
Wyoming
Kentucky
New York
Other
TOTAL
The following attachments may be required by the Tax Commissioner:
·
If taxpayer requests apportionment based on fleet miles:
1. DOR Motor Vehicle Division ( ) Form T-139 Schedule B for the International
Registration Plan (IRP).
2. List of year, make, VIN and Georgia County where taxes are paid for each vehicle in the fleet.
·
Evidence of ad valorem taxes paid in another state.
·
Evidence of highway use or motor fuel taxes paid in another state.
·
Evidence of registration fees paid to another state.
·
List of terminals in other states.
D: AFFIDAVIT
I hereby certify that the items of information entered on this form PT-95 and the attachments, if any, are true and correct to the best of my
knowledge and belief.
TAXPAYER NAME
DATE
E: APPORTIONED ASSESSMENT
(To be completed by Tax Commissioner)
1. Total miles allowed above
(a)
2. Total miles driven/traveled
(b)
. .
3. Apportionment ratio [ 1 minus (a)
(b) ]
(c)
4. Assessment value shown on MV-1 registration form
(d)
5. Apportioned assessment [ (c) times (d) ]
I have this date made the above apportioned assessment on the above listed vehicle. The taxpayer has _____ days from the
date of this assessment in which to file an appeal to the board of tax assessors.
TAX COMMISSIONER
DATE
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Parent category: Financial