Form Ifta-1 - International Fuel Tax Agreement (Ifta) - 2001 Page 2
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Type of fuel used (Check all that apply)
14.
1. Diesel
2. Motor fuel gasoline
3. Ethanol
4. Propane (LPG)
5. Other:
CNG
A-55
E-85
M-85
Gasohol
LNG
Methanol
15.
Place an “x” in the box next to any jurisdiction in which you travel.
AL - Alabama
IN - Indiana
NE - Nebraska
SC - South Carolina
Canadian Provinces
AK - Alaska
IA - Iowa
NV - Nevada
SD - South Dakota
AB - Alberta
AZ - Arizona
KS - Kansas
NH - New Hampshire
TN - Tennessee
BC - British Columbia
AR - Arkansas
KY - Kentucky
NJ - New Jersey
TX - Texas
MB - Manitoba
CA - California
LA - Louisiana
NM - New Mexico
UT - Utah
NB - New Brunswick
CO - Colorado
ME - Maine
NY - New York
VT - Vermont
NF - Newfoundland
CT - Connecticut
MD - Maryland
NC - North Carolina
VA - Virginia
NW - Northwest Territories
DE - Delaware
MA - Massachusetts
ND - North Dakota
WA - Washington
NS - Nova Scotia
DC - Dist. of Col.
MI - Michigan
OH - Ohio
WV - West Virginia
ON - Ontario
FL - Florida
MN - Minnesota
OK - Oklahoma
WI - Wisconsin
PE - Prince Edward Island
GA - Georgia
MS - Mississippi
OR - Oregon
WY - Wyoming
PQ - Quebec
ID - Idaho
MO - Missouri
PA - Pennsylvania
SK - Saskatchewan
IL - Illinois
MT - Montana
RI - Rhode Island
YU - Yukon Territory
16. Indicate the IFTA member jurisdiction(s) in which you maintain bulk fuel storage (enter none if you do not maintain bulk fuel storage).
17. Indicate any IFTA jurisdiction(s) in which you are currently or were previously registered (enter none if you have never been registered for IFTA).
18. Has your IFTA license ever been revoked in any IFTA jurisdiction? YES ___________ NO _____________
19. List any IFTA jurisdiction in which your IFTA license is currently revoked. _________________________________________________________________________________
The applicant agrees to comply with reporting, payment, record keeping requirements to report payments, keep records and
license display requirements as specified in the Massachusetts Tax Law and the International Fuel Tax Agreement. The
applicant further agrees that Massachusetts may withhold any refunds due if the IFTA applicant is delinquent on payment
of fuel taxes due any IFTA member jurisdiction. Failure to comply with these provisions shall be grounds for revocation of
an IFTA license in all member jurisdictions.
Under the penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief
it is true, correct and complete.
Type or print authorized signature
Title
Signature of owner, partner, member, officer, or person authorized by attached Power of Attorney
Tel. Number
Date
(
)
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