Form Amft-71 - Arkansas Ifta Application
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1Motor Fuel Tax Section
AMFT-71
P O Box 1752
Registration
Little Rock, AR 72203
Year
Phone. (501) 682-4815
Fax (501) 682-5599
ARKANSAS IFTA APPLICATION
Federal Employee ID Number or Social Security No.
1.
.
3. U.S. DOT Number
2. Arkansas IRP Account No
Expiration Date
4.
Applicant’s Legal Name
5. Application Type:
Original
Renewal
Supplement
6.
Trade/DBA Name (If different than Le gal Name)
7. Applicant’s Arkansas Phone Number
8.
Applicant’s Arkansas Physical Address
Street
City
State
Zip
9.
Mailing Address
Street or P.O. Box
City
State
Zip
10.
Contact Person’s Name
11. Contact’s Telephone No.
12.
Business Type:
Sole Proprietor
Partnership
Corporation
PRINT OR TYPE PARTNERS OR CORPORATE OFFICERS NAMES(S), TITLE, AND RESIDENCE ADDRESS
13.
NAME
TITLE
PHYSICAL RESIDENCE ADDRESS
14.
List Jurisdictions Where You Have Bulk Storage.
15.
NUMBER OF VEHICLES REQUIRING IFTA DECALS
NO FEE
CERTIFICATION – The applicant agrees to comply with reporting, payment, record keeping, and display requirements as specified in the
International Fuel Tax Agreement. The applicant authorizes the State of Arkansas to withhold any refund of tax overpayment if delinquent taxes
are due any member IFTA jurisdiction. Failure to comply with these provisions shall be grounds for revocation of the IFTA license in all
member jurisdictions and any falsification subjects him or her to appropriate civic and/or criminal sanction of the base jurisdiction.
APPLICANT AGREES, UNDER PENALTY OF PERJURY, THAT THE INFORMATION GIVEN ON THE IFTA APPLICATION IS,
TO THE BEST OF THEIR KNOWLEDGE, TRUE, ACCURATE, AND COMPLETE.
___________________________________
___________________________________
Applicant’s Signature
Applicant’s Title
Date
FOR OFFICE USE ONLY
Decal Registration Numbers:
Beginning _________________
Ending _____________
Date Mailed _________
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