Fillable Form Imc-2 - Idaho Motor Carrier Application

IMC-2

Idaho Motor Carrier Application - IFTA only

EFO00167 01-30-2012

Mail to: Idaho State Tax Commission

PO Box 36

Amount Paid

Name Control

Boise, Idaho 83722-0410

Phone: (208) 334-7806 (Boise Area)

Permit Number

ITD Account Number

(800) 972-7660, ext. 7806

2. Assumed business name (dba) (must match truck registration)

1. Legal business name (See instructions)

3. Federal employer identification number (EIN)

3a. Social security number (SSN)

4. US DOT Number

5. Type of

___Sole Proprietor

___Partnership

___S Corporation

___Corporation

___Corporation LLC

business entity

___Nonprofit

___Government

___Fiduciary

___Single Member LLC

___Partnership LLC

7. Highest GVW

6. Type of license

___ IFTA (International Fuel Tax Agreement)

8. Business

Street address

City

Location telephone number

State

Zip code

Location

( )

City

9. Business

Street address or PO Box

State

Zip code

mailing address

10. Mailing

Street address or PO Box

City

State

Zip code

Telephone number

address for

( )

report forms

Telephone number

FAX telephone number

11. Contact person

( )

12. Answer all of the following questions

Email address

Cell phone number

In which jurisdiciton is this fleet registered?

In which month does your tax year end?

When did trucking operations begin in Idaho?

Do you have bulk storage?___Yes ___No If yes, where?

Did you previously have any fuels tax accounts in Idaho?___Yes ___No If yes, list ALL licenses or account numbers.

Was this an existing business?___Yes ___No If yes, list previous business and owner's name.

What is the primary nature of this business? (What product/service, i.e., logging, farming, common carrier, etc.)

Have you ever been licensed in another IFTA jurisdiction?___Yes ___No If yes, list these jurisdictions.

If yes, is your IFTA license currently suspended or revoked in any jurisdiction?___Yes ___No

FEES - Idaho State Tax Commission

INTERNATIONAL FUEL TAX AGREEMENT LICENSE

13. Number of qualified motor vehicles in this fleet ........................................................................................................................... _________

14. Fee for new application ................................................................................................................................................................................... $

10.00

15. Decal sets needed (2 decals per set - 1 set required per vehicle) ______ Decal sets at $.60 per set ......................................................... $ __________

16. IFTA Fees (add lines 14 and 15) .................................................................................................................................................................

$ __________

List (a) owner, spouse, (b) partners, or (c) corporate officers. (Use additional sheet if necessary.)

17.

Name

Social Security Number

Address of Residence

CERTIFICATION: I certify that I am authorized as an owner, partner, corporate officer or representative to sign this document and that the statements made are correct

to the best of my knowledge. I agree to comply with reporting, payment, record keeping, and license display requirements as specified in the International Fuel Tax

Agreement. I further agree that Idaho may withhold any refunds due if I am delinquent on payment of fuel taxes due any member jurisdiction. Failure to comply with

these provisions shall be grounds for revocation of the license in all member jurisdictions. I agree, under penalty of perjury, that the information given on the IFTA

application is, to the best of my knowledge, true, accurate and complete.

Date

PRINT NAME:

Signature:

Title