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Form Mvd-10995 - Application For New Mexico Weight Distance Tax Identification Permit

STATE OF NEW MEXICO

Taxation and Revenue Department

Motor Vehicle Division

Bill Richardson

Jan Goodwin

Commercial Vehicle Bureau

Governor

Secretary

APPLICATION FOR NEW MEXICO WEIGHT DISTANCE TAX IDENTIFICATION PERMIT

INSTRUCTIONS FOR COMPLETING THE FORM:

Check the box which applies to this application:

Renewal: Check if motor carrier has or has had a New Mexico Weight Distance Tax account and is renewing permits.

Supplemental: Check if motor carrier is ordering additional permits.

Line 1. Enter the number of permits requested.

Line 2. Enter the total fees due: Multiply Line 1 by $2.00.

Check if affirming qualification as a one-way hauler. By checking the box, the registrant, owner or operator is affirming that the motor

carrier has one or more vehicles that qualify as a one-way hauler. To qualify as a one-way hauler entitled to a weight distance tax rate

reduction, the registrant, owner or operator is required to identify the vehicle as a one-way hauler at the time of registration. The

registrant, owner or operator must reasonably expect at the time of registration or re-registration that the vehicle will travel 45% or more of

all miles traveled in New Mexico empty of all loads. Note: One-way haulers are required to maintain documentation of loaded and empty

miles that each vehicle traveled in New Mexico (3.12.6.11, NMAC).

Sign and date the application. Enter the phone number of the registrant, owner or operator. Make the check or money order payable to

the attention of Taxation and Revenue Department. Mail the bottom portion of the application and payment to New Mexico Motor

Vehicle Division, P.O. Box 5188, Santa Fe, NM 87504-5188. For assistance contact (505) 827-0392.

please cut and include voucher with payment

Name:

Address:

WDT

Permit Year

MTD

EIN

NM DOT

US DOT

1.Number of permits requested

Signature: _______________________________

Phone:__________________ Date:___________

2.Total fees due

(multiply line 1 by $2.00)

One-Way Hauler

Mail voucher and payment payable to:

WDT

New Mexico Taxation & Revenue Department

Renewal

P.O. Box 5188

Supplemental

Santa Fe, NM 87504-5188

MVD-10995

Rev.09/2006

Form Mvd-10995 - Application For New Mexico Weight Distance Tax Identification Permit

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