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Instructions for MC-CCP, Credit Card Payment Authorization Form

for Motor Carrier Services Division

Note: This form is used if you choose to pay your fees using your Visa or Mastercard.

Legal Name: If you are a sole proprietor this will be your name. If you are a partnership enter the legal partnership name. If you are a

corporation enter the corporation name.

DBA Name: If your business entity is operating under a name other than your legal name, enter that name here. Otherwise enter

“N/A” if this does not apply.

Name on Credit Card: Enter the name that appears on the credit card.

Address: Enter the complete mailing address of the credit card.

Telephone Number: Enter the telephone number, including the area code, of the principal place of business.

DOT Number: Enter your US DOT number or Indiana ID number assigned to your motor carrier operation by either the U.S.

Department of Transportation or the Indiana Department of Revenue. Otherwise enter “N/A” if your are a new applicant.

FHWA/MC Number: Enter the motor carrier “FHWA” or “MC” number under which the Federal Highway Administration (FHWA) issued

your operating authority, if applicable. Otherwise enter “N/A” if this does not apply.

Taxpayer Identiﬁ cation Number: This is the Taxpayer Identiﬁ cation Number issued by the Indiana Department of Revenue. Otherwise

enter “N/A” if you are a new applicant.

FEIN/SSN: This is the Federal Employer Identiﬁ cation Number for corporations, partnerships, and LLC’s. Enter your social security

number if you are a sole proprietor.

International Registration Plan Number: This is your IRP (International Registration Plan) number issued by the Indiana Department

of Revenue. Otherwise enter “N/A” if you are a new applicant or this does not apply.

Fleet Number: This is the ﬂ eet number for your IRP account number. Otherwise enter “N/A” if you are a new applicant or this does not

apply.

Transaction Number: This is your transaction number for your IRP renewal. This can be found on your preprinted IRP renewal.

Otherwise enter “N/A” if you are a new applicant or this does not apply.

Reg. Year: This is the calendar year that you are remitting fees. Otherwise enter “N/A” if you are a new applicant or this does not apply.

Master Card or Visa: Mark the box that applies for the type of charge card you are using.

Account Number: This is your account number for the credit card you are using.

Expiration Date: Enter the expiration date for the credit card that you are using.

Amount: Enter the amount that you are authorizing the Department of Revenue to charge for a transaction with the understanding

additional credit card fees may apply on your card.

Put on ﬁ le:Check this option to put card on ﬁ le to use for future payments.

One Time Use: This option only gives permission to use this credit card for this transaction only with the understanding additional credit

fees may apply on your card.

Credit Card Holders Signature: The person that the credit card belongs to must sign the form in order to authorize the Department to

charge fees to that account.

To expedite your service, please be sure to fax your paperwork along with the credit card authorization form to the correct section. The

fax numbers per section are listed below.

UCR Fax Numbers

US DOT & UCR (317) 615-7374

MCFT & IFTA (317) 615-7333

IRP (317) 615-7280

OS/OW (317) 615-7241

Form Mc-Ccp - Credit Card Payment Authorization Form For Motor Carrier Services Division Page 2