Fillable Printable Form IRP-21 - IRP TEAR Request Form - New York

Form IRP-21 - IRP TEAR Request Form - New York

IRP TEMPORARY EVIDENCE OF APPORTIONED

REGISTRATION (TEAR) REQUEST FORM

(ATTACHMENT B)

Temporary Evidence of Apportioned Registration is requested for the following vehicle(s):

IRP ACCOUNT #: ________________________________

CARRIER NAME: ______________________________________________________________

OEN

PLATE # VIN

1) ____________ ____________________ ________________________________________

2) ____________ ____________________ ________________________________________

3) ____________ ____________________ ________________________________________

4) ____________ ____________________ ________________________________________

5) ____________ ____________________ ________________________________________

Total number of TEAR registrations requested: ________________

FAX NUMBER: ________________________________________________________________

CONTACT PERSON: ________________________________________________________________

PHONE NUMBER: ________________________________________________________________

WIRE SERVICE NAME: ________________________________________________________________

(if applicable)

I understand that the temporary evidence of apportioned registration is valid for 30 days, covers a specific

vehicle and is nontransferable. I agree to pay all fees and to provide all documents that are required of

me within 30 days from the date the temporary evidence of apportioned registration is issued. I understand

that my IRP account will be suspended if I do not pay the appropriate fees and provide the required

documents within this 30-day period.

(Signature of Registrant) (Date)

IRP-21 (7/15)

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