Form Mcs-3 - Motor Carrier Services Annual Report Form
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6MCS-3
Indiana Department of Revenue
State Form 48761
Motor Carrier Services
(R2 / 10-12)
Annual Report Form
For the Year Ending December 31, ______
th
Due April 30
** NOTICE **
On or before April 30th of each year, every motor carrier, who operated intrastate motor vehicles for-hire for household
goods and/or passengers, over the public highways of the State of Indiana, under a certifi cate or permit of public
convenience and necessity issued by the Department, shall fi le with the Department an Annual Report for the preceding
calendar year. You may fax your completed form to (317) 615-7374 or mail to Indiana Department of Revenue, Motor Car-
rier Services Division, 7811 Milhouse Road, Suite M, Indianapolis, IN 46241-9612.
Section A: Motor Carrier Information
Legal Name: ____________________________________________________________________________________
Doing Business As (DBA) Name: ____________________________________________________________________
Physical Address: ________________________________________________________________________________
City: __________________________________ State: ___________________ Zip Code: _____________________
Mailing Address: _________________________________________________________________________________
City: __________________________________ State: ___________________ Zip Code: _____________________
Contact Person\Title: __________________________________ Telephone Number: ___________________________
Email Address: _______________________________________
IMCA# /IN ID#: ______________________________________ US DOT Number: ____________________________
FEIN: ______________________________________________ SSN: ______________________________________
Medical Provider Number: ______________________________
Section B: Kind of Organization (check one)
A. ___ Individual
B. ___ Partnership
C. ____Corporation
D. ___ Other: ________________________________
Section C: Type of Motor Carrier (check all that apply)
1. ___ Common Carrier
2. ___ Contract Carrier
3. ___ Passenger Carrier
4. ___ Household Goods Carrier
Section D: Partnership (complete only if Section B Line B is checked)
Partner’s Name
Address
1.
_________________________________________
______________________________________________
2.
_________________________________________
______________________________________________
3.
_________________________________________
______________________________________________
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