Form R-5678-L - International Fuel Tax Agreement (Ifta) Application Page 2

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International Fuel Tax Agreement (IFTA) Application

R-5678-L (2/02)

❑

(A) Have you ever been issued an IFTA license?

Yes

If so, list jurisdiction(s). ____________

❑

(B) Have you ever been issued an IFTA license under any other name?

Yes

If yes, list name(s) and jurisdiction(s). ____________________________________________________

❑

Yes

(D) If you answered “yes” to (C), list name(s) and jurisdiction(s) ___________________________________

__________________________________________________________________________________

Reporting Firm Authorization:

Licensees are required to file application/returns and pay taxes as owed. They are also required to accept and

respond to various types of official communications with the Department of Revenue. If a licensee prefers a

reporting service to fulfill these responsibilities, a Power of Attorney completely and properly executed must

accompany this application. In the event the reporting service fails to fulfill their obligation to your firm, YOU will be

held ultimately responsible for the payment of taxes, as well as all acts and omissions of the reporting service.

Mail application and $35.00 application fee to:

Via United States Postal Service

or Via Overnight Delivery Service

Louisiana Department of Revenue

Taxpayer Services Division

Taxpayer Services Divison

Excise Section

P.O. Box 201

617 North Third Street

Baton Rouge, LA 70821-0201

Baton Rouge, LA 70802

Current Louisiana account number

The applicant agrees to comply with reporting, payment, record keeping, and license display

requirements as specified in the International Fuel Tax Agreement. Applicant also agrees that

Louisiana may withhold any refunds due if applicant is delinquent on payment of fuel taxes due any

member jurisdiction. Applicant further agrees to provide records or reimburse base jurisdiction for any

Current Special Fuels User license number

expenses associated with an audit if applicant’s records are maintained outside Louisiana. Failure to

comply with these provisions shall be grounds for revocation of license in all member jurisdictions.

I declare under penalty of perjury in the second degree that the statements made in this application are true and complete to the best of my knowledge.

Type or print authorized signature

Title

Signature of owner, partner, or corporate officer (required)

Date

Indicate name and address changes here.

LA account number ___________________________

Telephone____________________________________

Legal name ________________________________________________________________________________

Trade name ________________________________________________________________________________

Mailing address _____________________________________________________________________________

Location address ____________________________________________________________________________

8906