Form Reg-3-Mc - Application For Motor Carrier Road Tax - 2013

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Department of Revenue Services
2013
REG-3-MC
Calendar Year
State of Connecticut
PO Box 2937
Application for
If registered, enter
Hartford CT 06104-2937
Connecticut Tax Registration Number
Motor Carrier Road Tax
(Rev. 11/12)
Do not use this application to request International Fuel Tax Agreement (IFTA) decals.
Complete CT-IFTA-2 for IFTA decals.
Check if your mailing address has changed and
Use this application to register new accounts or additional
vehicles on existing accounts.
indicate new address.
Complete this application in blue or black ink only. Type or print all entries clearly.
Read the instructions printed on the back before completing this application.
1.
Reason for applying
New account
Registration of additional vehicles
Other (Explain)
2.
Owner’s name, partnership name, corporate name, or limited liability company (LLC) name
Federal Employer ID Number (FEIN)
3.
Trade name or registered name (if different from Line 2)
Social Security Number (SSN)
4.
Physical location of this business: PO Box is not acceptable.
ZIP code
Telephone number
(
)
5.
Business mailing address (if different from Line 4)
ZIP code
United States DOT Number
6.
Name and home address of owner, partner, corporate offi cer, or LLC member
ZIP code
SSN
7.
Name and home address of owner, partner, corporate offi cer, or LLC member
ZIP code
SSN
8. Type of ownership (If other, attach explanation.)
Other
Sole proprietor
General partnership
Limited partnership
Corporation
S corporation
Limited liability company (LLC)
Single member LLC
8a. Organized under laws of what state?
Check if taxed as a corporation
Check if taxed as a corporation
9. Are you currently registered with the Connecticut Department of Revenue Services (DRS)?
Yes
No
If Yes, enter your Connecticut Tax Registration Number in the space provided in the upper right corner of this application.
10. Describe in detail the type of business you operate.
2013
You are applying for identifi cation decals for calendar
year
. Your decals will expire December 31, 2013.
11. List lessors who lease vehicles to you. Attach additional sheets if needed.
Name
Address
Number of qualifi ed vehicles
Fee
Amount due
Fees: This section must be
completed by all applicants.
12. Enter total number of decal sets requested.
X $10 =
Make check payable to Commissioner of Revenue Services.
Declaration: The
undersigned
represents that: (1) All of the applicant’s qualifi ed motor vehicles will be operated solely within Connecticut during calendar year 2013;
(2) All of the motor fuel to be used in operating such vehicles will be purchased solely within Connecticut during calendar year 2013; and (3) Connecticut motor vehicle
fuels tax will be paid on all such purchases during calendar year 2013. The undersigned agrees to report immediately to DRS if any of these three representations
are no longer true or accurate. I declare under penalty of law that I have examined this application (including any accompanying schedules and statements) and,
to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fi ne
of not more than $5,000, or imprisonment for not more than fi ve years, or both. I understand motor carrier road tax decals may not be transferred by me to another
person or from one vehicle to another.
Signature of owner, partner, LLC member, or corporate offi cer
Title
Date
Email address of owner, partner, LLC member, or corporate offi cer
Decals are not transferable from vehicle to vehicle or from company to company

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