MC-CCP
Indiana Department of Revenue
State Form 51694
Credit Card Payment
(R3 / 10-12)
Authorization Form
For Motor Carrier Services Division
Use this form anytime you want to use a credit card to pay a fee for a Motor Carrier Services Division application.
Fax this Authorization form in with your Motor Carrier Services application(s) (i.e., BAS-2, IFTA-101, etc.) to the applicable
fax number, which can be found on the instructions for Credit Card Payment.
Please note: If you are faxing in applications and/or payments to more than one section, you must fax the applications and
credit card sheets to each individual section. You cannot combine payment types.
Legal Name: ____________________________________________________________________________________
DBA Name: _____________________________________________________________________________________
Name on Credit Card: _____________________________________________________________________________
Address: ___________________________
City: _________________ State: _____
Zip Code: ____________
Telephone Number: _______________________________________________________________________________
DOT Number _____________________________________
FHWA/MC Number ___________________________
TID Number ______________________________________
FEIN/SSN __________________________________
IRP Acct Number ___________
FLT Number __
TRANS #’S ____________
REG YEAR ______________
□
□
MasterCard
Visa
Account Number__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date____/_____
Amount $____________
Put on fi le __________
One Time Use __________
Month
Year
Cardholder Signature ____________________________________________________
I agree to the credit card processing fee calculated at $1 plus 2% of the total owed.