Form Mcft-1a - Intrastate Motor Carrier Fuel Tax Annual Permit Application
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4MCFT-1A
Indiana Department of Revenue
Intrastate Motor Carrier Fuel Tax
State Form 53994
(R2 / 3-13)
Annual Permit Application
Application Fee $25
Please print or type all information
Section A Taxpayer Information
Legal Entity Name
Indiana Taxpayer ID
Number (TID)
DBA Name
Federal Employer ID
(if applicable)
Number (FEIN)
Social Security
Number (SSN)
Address(es):
Indiana Physical Business Address
Tax Return and Correspondence Mailing
Credential/Decal Mailing Address
Address (if different from Physical)
(if different from Physical)
County
Business Entity Information:
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Sole Owner
Partnership
Corporation
LLC
Government
Other __________________________________
Please complete the following information if you selected a
Business Entity type of Corporation or LLC
A. State of incorporation
B. Date of incorporation
C. State of commercial domicile
D. If not incorporated in Indiana, enter the date authorized to do
business in Indiana
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E. If this entity is registered as an LLC, is this a Single-Member LLC?
Yes
No
Owner, Partner, and Corporate Officer Information:
SSN
(Social Security
numbers are required
Title
in accordance with
Last Name, First Name
(Owner, Partner, etc.)
Address
IC 4-1-8-1.)
Contact Person:
Name: _________________________________________________________
Telephone Number: _______________________
Email Address: __________________________________________________
Fax Number: ____________________________
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Please check this box if you elect to file online quarterly tax returns and renewals in the future.
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Parent category: Financial