Form Dr 7119 - International Fuel Tax Agreement (Ifta) Registration

Download a blank fillable Form Dr 7119 - International Fuel Tax Agreement (Ifta) Registration in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dr 7119 - International Fuel Tax Agreement (Ifta) Registration with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

DR 7119 (07/26/12)

Web

COLORADO DEPARTMENT OF REVENUE

Denver CO 80261-0009

International Fuel Tax Agreement (IFTA) Registration

Type of

Individual

General Partnership

Limited Liability Partnership

Limited Liability Company

Ownership

Corporation

Limited Partnership

Other (please specify): ___________________________

Taxpayer Name (owner, partners or other business organization) (last, first, middle)

Trade Name/Doing Business As (if applicable)

Address of Principal Place of Business

City

State

ZIP

County

City limits in which business is located (if applicable)

Telephone

(

)

Mailing Address (if different from above)

City

State

ZIP

County

Telephone

FEIN (if unavailable, SSN)

(

)

(1) Owner, Partner, or Corporate Name (last, first, middle initial)

SSN (FEIN if applicable)

Address (residence or P.O. Box, street, city, state, ZIP)

Telephone

(

)

(2) Owner, Partner, or Corporate Name (last, first, middle initial)

SSN (FEIN if applicable)

Address (residence or P.O. Box, street, city, state, ZIP)

Telephone

(

)

Jurisdiction

Year

1. Were you previously IFTA licensed in another jurisdiction?

Yes

No Jurisdiction

Year

2. Have you had an IFTA license revoked or cancelled by another jurisdiction?

Yes

3. In what state do you register your IFTA qualified motor vehicles under the IRP?

State

Year

US DOT Number

4. Do you have bulk facilities? If yes provide location of each facility (Attach list if necessary)

Yes

5. Check the type of fuel used in your qualified motor vehicles

Liability Date (Date Business Starts)

1. Diesel

2. LPG

3. Gasoline

4. Gasohol

License Period (MM/YY–12/YY)

5. LNG

6. CNG

7. Ethanol

8. Methanol

Registration Number

9. E-85

10. M-85

11. A55

Two IFTA decals per vehicle

“X” THE JURISDICTIONS IN WHICH YOU TRAVEL

Enter number here

Canadian Jurisdictions

AL - Alabama

IN - Indiana

NE - Nebraska

SC - South Carolina

AB - Alberta

AK - Alaska

IA - Iowa

NV - Nevada

SD - South Dakota

BC - British Columbia

AZ - Arizona

KS - Kansas

NH - New Hampshire

TN - Tennessee

__________________

MB - Manitoba

AR - Arkansas

KY - Kentucky

NJ - New Jersey

TX - Texas

NB - New Brunswick

CA - California

LA - Louisiana

NM - New Mexico

UT - Utah

NF - Newfoundland

CO - Colorado

ME - Maine

NY - New York

VT - Vermont

Decals issued by service center

NS - Nova Scotia

CT - Connecticut

MD - Maryland

NC - North Carolina

VA - Virginia

ON - Ontario

DE - Delaware

MA - Massachusetts

ND - North Dakota

WA - Washington

PE - Prince Edward IS

DC - Dist. of Col.

MI - Michigan

OH - Ohio

WV - West Virginia

QC - Quebec

FL - Florida

MN - Minnesota

OK - Oklahoma

WI - Wisconsin

______________

SK - Saskatchewan

GA - Georgia

MS - Mississippi

OR - Oregon

WY - Wyoming

ID - Idaho

MO - Missouri

PA - Pennsylvania

IL - Illinois

MT - Montana

RI - Rhode Island

Applicant agrees to comply with reporting, payment, recordkeeping, and license display requirements as specified in the International Fuel Tax

Agreement. The applicant further agrees that base jurisdiction may withhold any refunds due if applicant is delinquent on payment of fuel taxes due any

member jurisdiction. Failure to comply with these provisions shall be grounds for revocation of license in all member jurisdictions.

I declare under penalty of perjury in the second degree that the statements made in this application are true, accurate and complete to the best of my knowledge.

Type or Print Name

Title

Signature of Owner, Partner, or Corporate Officer (Required)

Date