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Application For The International Registration Plan (Schedule A) INIRP-A - Indiana

Application For The International Registration Plan (Schedule A) Form. This is a Indiana form and can be used in Motor Carrier Department Of Revenue Statewide .
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Form INIRP-A State Form 4947 (R2 / 2/11) State of Indiana Application for the International Registration Plan SCHEDULE A Please refer to the back for instructions. 1. Legal Name: 9. Mailing Address: 16. IRP Account /Fleet Number: 18. Staggered Month: 17. License Year: 2. Business Entity Type: Partnership Incorporation SECTION 1 Sole-Proprietorship Government Owned 10. County: 11. City: 19. New Account: Yes No 21. Account Contact Person's Name: 22. Contact Telephone Number: 23. Account Fax Number: 3. Federal ID Number (or Social Security Number if Sole-Proprietor): 4. Indiana Business Street Address: 5. County: 6. City: 7. State: 8: Zip Code: 12. State: 13. Zip Code: 14. Indiana Business Telephone Number: 15. E-mail Address: Last, First and Middle Initial: Social Security Number: Last, First and Middle Initial: Social Security Number: Below, please indicate the appropriate weight where proportional registration is sought in a jurisdiction. AB AK ID MS NV TN 2 Y e a r 3 M a k e AL IL MT NY TX 4 Vehicle Number AR IN MX OH UT 5 T y p e 6 Axles or Seats AZ KS NB OK VA 7 Motor Carrier U.S. DOT Number BC KY NC ON VT 8 Motor Carrier FEIN/SSN Responsible for Safety CA LA ND OR WA 9 Is Lease less than 30 days? Yes/No 10 F u e l CO MA NE PA WI 11 Unladen Weight CT MB NF PE WV 12 Declared Gross Weight 13 DC MD NH QC WY 14 Purchase Price DE ME NJ RI YT 15 Factory Price FL MI NM SC GA MN NS SD SECTION 2 IA MO NT SK 1 U n i t 16 Purchase Date 17 Owner Declared Combined Gross Weight SECTION 3 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 1 Schedule A Instructions SECTION 3 Line 1: Enter the Legal Name as it is registered with the Indiana Secretary of State or the Indiana Department of Revenue. (The IRP Unit will register the Applicant in the same name as registered with the Indiana Secretary of State or Indiana Department of Revenue.) Line 2: Enter the Business Entity Type as registered with the Indiana Secretary of State or Indiana Department of Revenue. Business Entity Types are Incorporation, Partnership, Sole Lines 3: ship. Enter the Social Security Number if registered as a Sole Proprietorship. Lines 4 through 8: Enter the Indiana physical address location of the place of business, where operational records can be attained and where Actual Miles are accrued. Line 9 through 13: Enter the mailing address where correspondence regarding the IRP Account is to be received by the Contact Person (designated on Line 22). Use the mailing address area on the Schedule B or BN to indicate the Fleet mailing address. Line 14: Enter the Indiana business telephone number. Line 15: Enter the email address for electronic communication with the IRP Unit. Line 16: Enter the Indiana IRP Account Number and Fleet Number. If the application is for the establishment of an new IRP Account, leave blank. Line 17: Enter the last two digits of the Registration Year which the Applicant is seeking proportional registration. Line 18: Enter the Staggered Month of the IRP account. Line 19: Enter an X in the appropriate box for determining if a New Account. Line 20: Line 21: Enter the name of the person who is responsible for conducting the Account's busiand the Contact Person Designee. Line 22: Enter the telephone number of the Contact Person. Line 23: Enter the account Fax Number. - Column 1: Enter the Registrant assigned Unit Number or Equipment Number for the vehicle. Column 2: Enter the last two digits of the Model Year of the vehicle. Column 3: Enter the Vehicle Make using the three letter abbreviation that is shown on the vehicle title or title application. Column 4: of Title or Title Application. Column 5: Enter the type of vehicle. Vehicle Types: TK - Truck (single), TR-Tractor, TT-Truck Tractor, RT-Road Tractor, ST-SemiTrailer, FT-Full Trailer, BS-Bus, WR-Wrecker, CG-Converter Gear. (Use only the abbreviation.) For a complete description and illustration, please refer to the IRP Manual. Enter "5ST" for Five-Year Semi-Trailer plate or "PST" for Permanent Semi-Trailer plate. Column 6: Enter the number of Axles, including axles in a tandem group. If registering a Bus, indicate the rated Seat capacity. Column 7: Enter the Motor Carrier US DOT Number of the entity responsible for the vehicle Lease Agreement. Column 8: Enter the Motor Carrier Responsible for Safety FEIN / SSN (TIN). Column 9: Enter Y or N if Lease is Less Than 30 Days. Column 10: Enter the Fuel Type. Fuel Types are as follows: D-Diesel, G-Gasoline, P-Propane, O-Other. (Use only the abbreviation.) Column 11: Enter the weight of the vehicle fully equipped for service excluding the weight of any load. Column 12: Enter the total unladen weight of the vehicle plus the maximum load to be carried on the vehicle. Column 13: Enter the total unladen weight of the cominbation of vehicles plus the maximum load to be carried on that combination of vehicles. Column 14: Enter the actual purchase price of the vehicle paid by the current owner, excluding Column 15: Enter the manufacturer's retail price excluding trade in and sales tax, including Column 16: Enter the month, day and year in which the vehicle was purchased by the current owner. Column 17: Enter the name of the titled owner, if the vehicle is not owned by the Applicant. SECTION 2 Indicate the appropriate weight in the jurisdiction for the vehicle(s) in Section 3. The weight must be the "Declared Combined Gross Weight" or the "Declared Gross Vehicle Weight" as shown in Section 3, Column 13. American LegalNet, Inc. www.FormsWorkFlow.com
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