Fillable Printable Tc-853, Irp Supplemental Application Schedule C
Fillable Printable Tc-853, Irp Supplemental Application Schedule C
Tc-853, Irp Supplemental Application Schedule C
My signature below acknowledges that I understand and will comply with the reporting, payment, record keeping, and license display requirements as specified in the International
Registration Plan.I understand that failure to comply with the provisions, shall be grounds for revocation of my registrations in all member jurisdictions.Under penalty of law, I certify, under
the penalties of perjury, that the information herein is true, correct, and complete.
Utah Special Fuel/IFTA:I hereby certify that I have qualified with the Utah State Tax Commission and that I will make reports as required, under the federal identification number listed
on this form.
Signature of person completing application
Date signed
**Will the control and responsibility for the safety of this vehicle be assigned to a different Motor Carrier during the registration year by lease?
** Action codes:A - Add vehicle R - Renew vehicleW - Weight change C - Change vehicle
**Type key:BS-Bus C-Cement Pumper CG-Converter Gear CR-Crane DB-Double Bottoms DT-Dump Truck LG-LogTruck
RT-RoadTractorTK-Truck (single)TL-Full-Trailer orTR -TractorTT-Truck/TractorW-WellborerWK-Wrecker/TowTruckSemi-Trailer
**Fuel Key:D-Diesel G-Gasoline GH-Gasohol N-Natural P-Propane
JURISDICTION USE ONLY
HVUT verified ________________________
I/M verified __________________________
The original cab card and license plate must be surrendered on all deleted
units within 10 business days in order to transfer fees.
Equipment
number
Plate
VIN
Deletions
***?Does truck pull a trailer
AB
AK
QC
(see note)*
AL
AR
AZ
BCCA
CO
CT
DCDE
FL
GA
HI
IA
lD
lL
lN
KSKYLA
MB
MD
ME
MI
MN
MO
MS
MT
MX
NB
NC
ND
NENFNH
NJNM
NS
NTNV
NY
OH
OK
ON
OR
PA
RI
PRSCSD
WY
YT
TN
SK
TX
UT
VA
VT
WA
WI
WV
MA
Name of applicant
Business street address (where records are kept - must be a Utah physical address)
City
Type of operation (check the ONE that applies)
CountyState
ZIP code
Mailing street address
Business telephone number (must be a Utah number)
CityStateZIP code
License year
Person to contact regarding application
Contact's city
Contact's state
U.S.DOT number
Utah IFTA account number
Application effective date
Contact's fax number
Contact's telephone number
Fleet
Account number
Supplemental Application - Schedule C
UT-
UT
Utah StateTax Commission - Motor Carrier Services - IRP
MAR 31
Registration period (check one)
SEPT 30
JUN 30
DEC 31
Federal ID (FEIN/EIN)
Telephones:(801) 297-6800 or 1-888-251-9555;Fax (801) 297-6899
If previously prorated in another state provide
previous state and account number
State:_________________________
Account no.:____________________
TC-853 Rev.7/07
RegisteredWeights (list on this schedule only the units that will operate at the same weight in the IRP jurisdictions) - if traveling in Quebec, list the total combined axles for power units/trailers and the gross weight for buses)
Ye sN o
Do you currently haveWyoming intrastate operating authority?
For hirePrivate
Ye s
No
Is this an organization exempt from property tax?
Equipment
number
Name of owner
Year
Type*
Action
code*
Make
Fuel*
Vehicle Identification number
Unladen
weight
Declared
combined
gross weight
License
plate
number
Plate
Title
Temp.
Factory
price
Purchase
price
Date of
purchase
Axles/
Seats
Less than
10K/miles
US DOT
number
FEIN/EIN
Carrier responsible
for safety of vehicle
Property
tax
1 yr.2 yr.
Y/N
**
Y/N
***
Owned
Leased
Leased
start date
Leased
end date
**
Bus (gross weight)
Power unit (total axles of power unit &
trailer combined) -
Rental
only if rental
is less than
45 days
ExemptHousehold goods
Clear form
