Fillable Printable Motor Carrier Ifta Licenseand Decals Application

Motor Carrier Ifta Licenseand Decals Application

IFTA License and Decals Application

Why are you being asked to share this information and how will it be used?

The Department of Public Safety (DPS) will use the information to identify you as a registrant or authorized agent of the

registrant, to create or identify your Minnesota prorate account, to determine your eligibility for a Minnesota IFTA license and

decals, to access your record for any future service transactions and/or inquiries, and to comply with state and federal laws.

State law authorizes collection of this information.

The International Fuel Tax Agreement (IFTA) entered into under the authority of Minnesota Statutes, section 168.187, subdivision

7, requires this information.

Consequences of supplying or refusing to supply requested information.

If you supply the requested information, the DPS will be able to determine whether to issue you a Minnesota IFTA license and

decals. If you don’t provide the information requested, the DPS cannot issue you a Minnesota IFTA license and decals and your

eligibility for any current registration may be affected.

How is the requested information shared with other agencies?

The DPS releases this information to local, state, and federal government agencies only as authorized or required by state and

federal law. This means that the information may be shared with the Federal Motor Carrier Safety Administration (FMCSA) and

IRP member states. In addition, your personal information may also be disclosed as authorized in the United States Code, title

18, section 2721.

Permissible Uses of Motor Vehicle Data as prov ided in Unite d States Code, title 18, section 2721

1. For use by any government a gency, including court or la w enforcement agency, in carr ying out its functions, or any private person

or entity acting on behalf of a feder al, state or local agency in carrying out its functions.

2. For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product

alterations, recalls or advisor ies; performance monitoring of motor vehicles , motor vehicle parts and dealers; motor vehicle ma rket

research activities, including s urvey research; and removal of non-owner records from the original o wner records of motor vehicle

manufacturers.

3. For use in the normal course of busin ess by a legitimate business or its agents, employees, or contractors, but only:

(A) to verify the accuracy of personal information submitted by the individual to the business or its agencies, employees, or

contractors; and

(B) if such information as so submitted is not correct or is no longer correct, to obtain correct information, but only for the purposes

of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest agai nst the individual.

4. For use in connection with any civil, criminal, administrative, or arbitral proc eeding in any federal, state or local court or agenc y or

before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or

enforcement of judgments and orders, or pursuant to an order of a federal, state or local court.

5. For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, re-

disclosed, or used to contact individu als.

6. For use by any insurer or insurance support organization, or by self-insured entity, or its agents, employees, or contractors, in

connection with claims investigation activities, antifraud activities, rating or underwriting.

7. For use in providing notice to the owners of towed or impounded vehicles.

8. For use by any licensed private investigative agency or licensed security service for any purpose permitt ed under this subsection.

9. For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver’s license

that is required under the Commercial Motor Vehicle Safety Act of 1986 (49 U.S.C. App. 2710 et seq.).

10. For use in con nection with the operation of private toll transportation facilities.

11. For any other use in response to requests for individual motor vehicle re cords if the state has obtained the express consent of the

person to whom such personal information pertains.

12. For bulk distribution for surveys, marketing, or solicitations if the state has obtained the express consent of the person to whom

such personal information pertains.

13. For use b y any requester, if the requester demonstrates it has obtained written consent of the individual to whom the information

pertains.

14. For any other use specifically authorized un der the la w of the state that holds the record, if such use is related to the operati on of a

motor vehicle or public safet y.

PS2261-18 Rev. 10/2008 Minnesota Department of P ublic Safe ty Driver and Vehicle Services Division

445 Minnesota Street, Saint Paul, Minnesota 55101-5188 Office: (651) 205-4141 or TTY: (651) 282-6555

_____________________________________________________________ _______________________

IFTA License and Decals Application Registration Year: _______

New/Renewal License Exemption Extra Decals Change Account Informa tion

Cancel Account (Attach license and decals) or check box if destroyed, lost, mutilated

Prorate Account Name (print): Prorate Acct. #

Physical Address of Business: FEIN: USDOT #

Business Mailing Address: Contact Phone:

Exemptions – If you qualify for one of the following exemptions, check the appropriate box and sign this application.

Company holds a current IFTA license in a jurisdiction other than MN.

Jurisdiction: ___________Acct. #: ______________________

Leased to carrier that reports fuel tax.

Carrier name: ____________________________ Jurisdiction: ___________ Acct. #:_______________________

Operating only two-axle vehicles with gross vehicle weight of 26,000 poun ds or less.

If you do not qualify for an exemption, complete items 1 through 8 and sign this application.

1. Print names and titles of:

Owner(s) Partner(s) Corporate officer(s)

(Name)(Name)

(Title)(Title)

2. Fuel type(s) used (check all that apply):4. Is your fuel return for a consolidated fleet

(vehicles registere d in another IRP jurisdiction)?

Diesel Gasoline Other _____________

NO YES in: ________________________

3. Do you maintain bulk storage?

NO YES in MN YES in: __________

IFTA Fees and Decals: If requesting extra decal s only, do not include annual filing fee and annual license fee.

License and decals for the upcoming year must be displayed by Febru ary 28.

New/Renewal: Annual filing fee

Annual license fee

$10

$28

Decals: _______(vehicles) x $2.50 $

Grand total $

Mail this application and check/money order for Grand total to:

Prorate Office

445 Minnesota Street

Saint Paul, Minnesota 55101-5188

Make check/money order payable to Driver & Vehicle Services

I hereby affirm that the information provid ed is true, correct, and complete. I agree to comply with reporting, payment, record

keeping, and license display requirements as specified in the International Fuel Tax Agreement (IFTA). I understand that failure to

comply with these provisions is grounds for revocation of the IFTA license in all member jurisdictions and that the base jurisdiction

may withhold any refunds due if I am delinquent on payment of fuel taxes due any member jurisdiction.

(Signature of Taxpayer)(Title) (Date)

PS2261-19 Rev. 12/15

Minnesota Department of P ublic Safe ty Driver and Vehicle Services Division

445 Minnesota Street, Saint Paul, Minnesota 55101-5188 Office: (651) 205-4141 or TTY: (651) 282-6555