- Form DS-885 - Bus Driver Add/Drop Notice - New York
- Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
- Form DS-874C - Supplement to: Medical Examination of Driver Report - New York
- Form IRP-21 - IRP TEAR Request Form - New York
- Form DS-19 - Motor Carrier Accident and Conviction Notification Program Application - New York
- Form DS-3 - Article 19-A Annual Affidavit of Compliance - New York
Fillable Printable Form IRP-5 - Schedule B Distance Information (2014) - New York
Fillable Printable Form IRP-5 - Schedule B Distance Information (2014) - New York
Form IRP-5 - Schedule B Distance Information (2014) - New York
New York State Department of Motor Vehicles
INTERNATIONAL REGISTRATION PLAN
SCHEDULE B DISTANCE INFORMATION
32. REG YEAR: __________ 33. ACCOUNT #: __________________ 34. FLEET #: _________ 35. CARRIER: ______________________________
IF THIS IS A NEW ACCOUNT/FLEET AND YOU DO NOT HAVE ANY ACTUAL DISTANCE FOR THE PREVIOUS DISTANCE PERIOD (7/1 - 6/30)
CHECK THIS BOX. THE AVERAGE PER VEHICLE DISTANCE CHART WILL BE USED FOR FEE CALCULATION.
IF ACTUAL DISTANCE WAS TRAVELED DURING PREVIOUS DISTANCE PERIOD (7/1 - 6/30) COMPLETE CHART BELOW.
CERTIFICATION: I, the Undersigned, certify under penalty of perjury that the information provided in this Distance Schedule is true and accurate to the best
of my knowledge and that the actual distance travelled, as reported on this form, is supported by the distance records maintained. I understand and acknowledge
my duty to: (a) maintain such records in compliance with IRP recordkeeping requirements for a period of six (6) years from the date of completion of each
trip; (b) promptly make such records available for audit, at any time deemed appropriate by DMV; (c) reimburse DMV for auditor travel expenses incurred
should audit require travel outside New York State; and (d) submit to monetary assessments and/or non-monetary sanctions of suspension or cancellation of
my IRPâaccount as DMV deems appropriate.
If this Distance Schedule is signed in my official capacity on behalf of the Carrier, I further certify that I am duly authorized to make this Certification on behalf
of such entity.
STATE ACTUAL
DISTANCE
AK (Alaska)
MI (Michigan)
VA (Virginia)
VT (Vermont)
WA (Washington)
WI (Wisconsin)
WV (West Virginia)
WY (Wyoming)
CANADA
AB (Alberta)
BC (British Columbia)
MB (Manitoba)
NB (New Brunswick)
NL (Newfoundland/
Labrador)
NS (Nova Scotia)
NT (Northwest Terr.)
ON (Ontario)
PE (Prince Edward Isl.)
QC (Quebec)
SK (Saskatchewan)
YT (Yukon)
MX (Mexico)
AL (Alabama)
AR (Arkansas)
AZ (Arizona)
CA (California)
CO (Colorado)
CT (Connecticut)
DC (Dist. of Col.)
DE (Delaware)
FL (Florida)
GA (Georgia)
IA (Iowa)
ID (Idaho)
IL (Illinois)
IN (Indiana)
KS (Kansas)
KY (Kentucky)
LA (Louisiana)
MA (Massachusetts)
MD (Maryland)
ME (Maine)
IRP-5 (11/14)
STATE ACTUAL
DISTANCE
MN (Minnesota)
MO (Missouri)
MS (Mississippi)
MT (Montana)
NC (North Carolina)
ND (North Dakota)
NE (Nebraska)
NH (New Hampshire)
NJ (New Jersey)
NM (New Mexico)
STATE ACTUAL
DISTANCE
NV (Nevada)
NY (New York)
OH (Ohio)
OK (Oklahoma)
OR (Oregon)
PA (Pennsylvania)
RI (Rhode Island)
SC (South Carolina)
SD (South Dakota)
TN (Tennessee)
TX (Texas)
UT (Utah)
(36)
REGISTRANT/
Title:
-
Name of Registrant/Carrier (please print):
Sign here:
Date (mm/dd/yyyy): / /
If signing as agent for a business entity, write your title (CEO, President, Vice-President,
Secretary, Treasurer or Comptroller). Anyone else signing as agent for a business entity must
send in an original Power of Attorney.
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