Form Prop-1 - Proportional Use Credit Certification Application

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Indiana Department of Revenue
Proportional Use Credit
Certification Application
PROP-1
Fee $7.00
Rev. 08/00
Complete this Section only if different than lines 1, 3, 5, 6, 7.
1. Legal Name
2. Doing Business As (DBA)
3. Physical Address
4. Mailing Address
5. City
6. State/Province
7. Zip Code
8. City
9. State/Province
10. Zip Code
11. County
12. Telephone Number
13. Federal Identification Number
14. Social Security Number
(
)
15. Interstate U.S. DOT Number
16. Indiana IFTA Number
17. IFTA Number (If Non-IN. IFTA)
18. Base State/Jurisdiction
19. Indiana U.S. DOT Number
20. Indiana Motor Carrier Number
21. E-Mail Address
NOTE: If you ARE NOT an Indiana IFTA/Motor Carrier Account and are registered in another jurisdiction,
proceed to line 22. All others go to line 24.
22. Check the type of organization of this business:
Sole Proprietorship
Partnership
Corporation
Government
Other ______________
23. Non-Indiana Based Corporation must provide the following information:
State of Incorporation:
Date of Incorporation:
State of Commercial Domicile:
Enter the date authorized to do business:
Accounting period year ending date (MM/DD):
Non-Indiana Based Corporation - List Name of Owner, Partners or Officers (Attach additional sheets)
Last Name, First, Middle Initial
Title
Street Address
City
State
Zip
Social Security Number
I do hereby certify under penalty of perjury that the foregoing and attached information is a true and correct statement to the best of my knowledge
and is a complete and full representation based upon the best information available.
24. Signature of Taxpayer/Authorized Agent
Typed or Printed Name
Title
-
Date Signed
Telephone Number
(
)
This application MUST be signed by the owner, general partner or corporate officer before it will be processed by the Department.
For more information regarding this application, you may contact the Department at (317) 615-7345. Mail completed application, all relevant
documentation and application fees to:
Indiana Department of Revenue
Motor Carrier Services Division
P.O. Box 6078
Indianapolis, IN 46241-6078

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