Form Mcs-1789 - Claim For Proportional Use Credit
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3MCS-1789
Indiana Department Of Revenue
Departmental Use Only
State Form 49868
Motor Carrier Services Division
(R2 / 3-13)
Total Gallons
_______________
Claim For Proportional Use Credit
Total Miles
_______________
Indiana Amount Paid _______________
Quarter ________ Year _________
Total Amount Paid
_______________
Claimant’s Name
Indiana TID Number
Non-Indiana Based IFTA Number
Interstate or Indiana US DOT Number
Complete This Section Only If Changing Address Or Telephone Number.
Street Address
City
State
Zip
Telephone Number
You Must Submit With This Claim For Credit
•
MCFT-101/IFTA-101 or
•
Out of State Return
Please refer to instructions before proceeding. Attach additional sheets if necessary.
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Vehicle
Number of
Eligible Miles
Eligible Gallons
Exempt
Proportional
Tax Rate
Refund
Type Codes
Vehicles
Traveled
Consumed
Percentage
Use Exempt
Claimed
(See
(Use Whole
(See
Gallons
Col. 6 x Col.7
Instructions)
Gallons)
Instructions)
Col.4 x Col.5
(Use Whole
Gallons)
%
.27 $
%
.27 $
%
.27 $
%
.27 $
%
.27 $
%
.27 $
%
.27 $
%
.27 $
Total Refund Due $
Applicant agrees, under penalty of perjury, that the information given on this form is, to the best of their knowledge, true, accurate,
and complete. The applicant further attests that the attached quarterly tax return is a true and accurate copy of the return fi led with the
based jurisdiction. This form must be signed by an owner, partners, or a corporate offi cer or by an authorized agent. If signed by an
authorized agent, a properly completed power of attorney must be enclosed with this form. Mail the completed form to the Indiana
Department of Revenue with your quarterly return.
Signature of Taxpayer or Authorized Agent
Typed or Printed Name
Title
Date Signed
Telephone Number
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