Form Ifta-21 - New York State International Fuel Tax Agreement (Ifta) Application - 2015
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1Department of Taxation and Finance
IFTA-21
New York State International Fuel
(9/15)
Tax Agreement (IFTA) Application
For office use only
1a This application is for calendar year
1b Reason for application
New
Additional license
$
Number
Renewal
Additional decals
2 Identification
Employer identification number Suffix, if any
Social security number
Deposit number
number
OR
SS
3 Type of business
Sole proprietor/individual
Corporation
Partnership
LLC/LLP
Other:
4 Legal name
5 USDOT number
6 Doing business as (DBA) name
7 Business phone number
(if different from legal name)
(
)
8 Physical address
9 Mailing address
(number and street)
(if different than physical address; number and street or PO box)
City
State
ZIP code
City
State
ZIP code
10 Will you be traveling outside New York State?
11 Are you registered for New York State highway use tax?
12 IRP registration number
Yes
No
Yes
No
If No, see instructions
13 Have you ever had an IFTA license from a state other than New York?
Yes
No
If Yes, list state(s):
14 Do you have bulk fuel storage?
Yes
No
If Yes, list in which state(s):
Decal order
15 Number of IFTA vehicles:
x $8 per set of 2 decals
.
= ...... 15
(see instructions)
00
and enter 2 on line 16 ......... 16
.
16 Additional license
($2 fee; mark an X in the box if needed)
00
.
17 Total due
............................................ 17
(add lines 15 and 16; see below for how to pay)
00
•
•
Pay the fees (total due)
Make check or money order payable in U.S. funds
with this application
to Commissioner of Taxation and Finance
Certification: The applicant agrees to comply with reporting, payment, recordkeeping, and license-display requirements as specified in the New York
State Tax Law and the International Fuel Tax Agreement. The applicant further agrees that New York State may withhold any refunds due if the IFTA
applicant is delinquent on payment of fuel taxes due to any IFTA member jurisdiction. Failure to comply with these provisions shall be grounds for
revocation of any IFTA license in all member jurisdictions.
I certify with my signature that to the best of my knowledge and belief, the information on this application is true, correct, and complete. I understand
that any falsification may subject me to civil and criminal sanctions found in Tax Law section 1815, and Penal Law sections 175.35 and 210.45.
Type or print name of person signing
Title
Signature of owner, partner, member, officer, or person authorized by attached Power of Attorney
Telephone number
Date signed
(with area code)
(
)
For mailing instructions, see Form IFTA-21-I, Instructions for Form IFTA-21.
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