International Fuel Tax Agreement (Ifta) New Carrier Application - 2014

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Montana Department of Transportation
Motor Carrier Services Division
PO Box 4639
Helena MT 59604-4639
(406) 444-2998
International Fuel Tax Agreement (IFTA)
IFTA License #:
New Carrier Application
Effective Date: (enter the date you would like your
1. Business Federal Employer ID #
2. USDOT # (Required)
license effective)
3.Legal Name:
Trade Name (DBA):
4. Mailing Address - Line 1
7. Physical Address - Line 1 (If Different from Mailing Address)
5. Mailing Address - Line 2
8. Physical Address - Line 2
6. City
State
Zip Code
9. City
State
Zip Code
10. Business Phone #
11. Fax Number
12. Email Address:
13. ‘X’ Type of Organization
14. Social Security #
15. Identify Owners, Partners, or Corporate Officers
Sole Proprietor
Social Security #
Name and Address
Partnership
Corporation
LLC
LLP
Other
15. Do you maintain bulk storage in Montana?
Yes
No
17. List Other States Where Bulk Fuel is Maintained:
18a. Have you ever been licensed in another jurisdiction?
Yes
No b. Has your IFTA license ever been revoked?
Yes
No
19. The Jurisdictions in which you operate: (‘X’ all that apply)
AB – Alberta
KS – Kansas
NH – New Hampshire
RI – Rhode Island
AL – Alabama
KY – Kentucky
NJ – New Jersey
SK – Saskatchewan
AZ – Arizona
LA – Louisiana
NM – New Mexico
SC – South Carolina
AR – Arkansas
ME – Maine
NY – New York
SD – South Dakota
BC – British Columbia
MB – Manitoba
NL – Newfoundland
TN – Tennessee
CA – California
MD – Maryland
NC – North Carolina
TX – Texas
CO – Colorado
MA – Massachusetts
ND – North Dakota
UT – Utah
CT – Connecticut
MI – Michigan
NS – Nova Scotia
VA – Virginia
DE – Delaware
MN – Minnesota
OH – Ohio
VT – Vermont
FL – Florida
MS – Mississippi
OK – Oklahoma
WA – Washington
GA – Georgia
MO – Missouri
ON – Ontario
WV – West Virginia
ID – Idaho
MT – Montana
OR – Oregon
WI – Wisconsin
IL – Illinois
NE – Nebraska
PA – Pennsylvania
WY – Wyoming
IN – Indiana
NV – Nevada
PE – Prince Edward Isl.
IA – Iowa
NB – New Brunswick
QC – Quebec
ALL – All Jurisdictions
20. Fuel Decals for IFTA Units – Decal Fees must be sent with this application.
Number of vehicles requiring fuel decals
x $2.00 =
Under penalties of perjury, I certify with my signature that to the best of my knowledge the information and statements on
this application are true and correct and the number shown on this form is my correct taxpayer identification number. I
agree to comply with reporting, payment, record keeping and license display requirements as specified in the International
Fuel Tax agreement and Montana State Statutes. I further agree that Montana may withhold any refunds due me if I become
delinquent in payment of fuel taxes, whether due Montana or any IFTA member state. I also understand that failure to
comply with these provisions shall be grounds for revocation of my fuel tax license(s).
Authorized Signature
Date
Title
See Reverse for Instructions
Reverse Must be Completed
S:IFTA:MF91R Revised 06/14
Chapter 70, Title 15, MCA

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