Fillable Printable Motor Carrier Temporary Reg Authority Fax Cover Sheet

Motor Carrier Temporary Reg Authority Fax Cover Sheet

Temporary Registration Authority Cover Sheet

(This form must accompany each request)

PS2269-01 Rev. 5/2007 Minnesota Department of Public Safe ty Driver and Vehicle Services Division

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

Today’s Date:

To: Minnesota Prorate Office Fax: 651.215.0027

From: Phone Number:

Carrier Name: Prorate Account #:

Carrier Fax Number: Total Pages:

Temporary Registration Authority (TA) will not be issued without full payment of registration and sales tax,

as required by Minnesota Statutes, sections 168.183, subdivision 3; 168.187, subdivision 11; and 297B.06.

On behalf of the above named carrier, I request the following service (check all that apply):

Fax Temporary Authority and billing invoice (PS2262 EFT Authorization form must be attached).

Note: We cannot guarantee same day service

Fax invoice only. (Allow three business days for processing)

To pick up credentials at Town Square Office. (Allow three business days for processing)

Please check one (required for new purchase):

Titling in Minnesota (sales tax required; see above)

Titling out of state (Non-resident owner)

Already titled in Minnesota

By signing this document, I understand that once a Temporary Authority (TA) is issued on a vehicle, it cannot

be retracted. I may be able to utilize this unit as a deletion on a future transaction.

______________________________________________________ Date: _____________________

(Signature Required)