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International Registration Plan New Account (Schedule BN) INIRP-BN - Indiana

International Registration Plan New Account (Schedule BN) Form. This is a Indiana form and can be used in Motor Carrier Department Of Revenue Statewide .
 Fillable pdf Last Modified 2/15/2011
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Form INIRP-BN State Form 4949 (R4 / 12-10) Indiana Department of Revenue International Registration Plan New Account Schedule BN 7. Fleet Mailing Address 3. County 5. State 6. ZIP Code 8. County 10. State 9. City 11. ZIP Code 12. IRP Account Number 14. New Account Yes No 15. Type of Carrier (check only one) Private Carrier Exempt Commodity Carrier Household Goods Carrier 13. Fleet Number Section 1 1. Registrant Name 2. Fleet Street Address 4. City In Section 2, place an X in the column to the right of the jurisdictions where proportional registration is sought. * NR - Non Reciprocity Jurisdiction AB Alberta AR Arkansas CA California DC Wash. D.C. GA Georgia IL Illinois LA Louisiana MD Maryland X Mileage 72 2,384 7,054 10 3,324 5,920 1,710 1,242 849 544 3,538 10 1,880 1,170 2,167 6,580 82 37 1,392 101 2,334 1,075 Jurisdiction AK Alaska AZ Arizona CO Colorado DE Delaware IA Iowa KS Kansas MA Massachusetts ME Maine MO Missouri MX Mexico ND N. Dakota NH N. Hampshire NS Nova Scotia NY New York ON Ontario PE Prince Ed. Is. SC S. Carolina TN Tennessee VA Virginia WA Washington WV West Virginia YT Yukon Terr. X NR Mileage Jurisdiction AL Alabama X Mileage 2,713 35 669 3,073 701 3,361 21 2,782 2,093 10 1,073 2,308 Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, complete and correct, and I am providing proof of financial responsibility prior to affixing my signature hereto. I agree Yes No 16. Please designate the appropriate year for the Mileage Reporting Period of July 1, __________ through June 30, __________. 17. If your Estimated Miles differ than those shown in Section 2 , please attach a Schedule G. "For Hire" Carrier (Common Carrier) 2,373 1,613 238 1,656 1,361 766 152 3,228 NR BC British Col. CT Connecticut FL Florida ID Idaho KY Kentucky MB Manitoba MI Michigan MS Mississippi NB New Bruns. Section 2 MN Minnesota MT Montana NC N. Carolina NF Newfoundland NM New Mexico NV Nevada OK Oklahoma PA Pennsylvania RI Rhode Island SK Saskatchewan UT Utah VT Vermont WI Wisconsin WY Wyoming 185 115 10 2,956 452 10 2,226 4,470 3,373 1,643 1,080 NR NE Nebraska NJ New Jersey NT Northwest T. NR OH Ohio OR Oregon QC Quebec SD S. Dakota TX Texas For Official Use Only IN Indiana Miles NR Miles Total Fleet Miles 7,520 1,652 49 219 6,641 Section 3 Signature of Owner or Responsible Officer Title Date Name of your Insurance Company (not the agency or group) ( ) 7,650 Policy Number Insurance Company Phone Number Address of Insurance Company American LegalNet, Inc. www.FormsWorkFlow.com Schedule BN Instructions SECTION 1 Line 1: Enter the Applicant 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 the Indiana Department of Revenue. If the name as registered with the Indiana Secretary of State or the Indiana Department of Revenue differs from the title or title application name, a Lease Agreement or title change is required.) Line 2 through 6: Enter the FLEET Street Address if different than the Indiana Business Street Address on the Schedule A. Lines 7 through 11: Enter the Fleet Mailing Address if different than the Applicant Mailing Address on the Schedule A. Each FLEET may have an independent mailing address where credentials or other correspondence regarding this FLEET is received from the IRP Unit. Line 12: Enter the Indiana IRP Account Number. Line 13: Enter the Fleet Number, if applicable. Line 14: Enter an X in the appropriate box for determining if a New Account. Line 15: Enter the Type of Carrier. Check only one. SECTION 2 Place an X in the column to the right of the jurisdictions where proportional registration is sought. The Estimated Miles for each jurisdiction are based upon the total Actual Miles traveled by proportionally registered vehicles in the jurisdiction, during the previous Mileage Reporting Period. To use other Estimated Miles, see Section 3, Line: 22. NOTE: If qualified under 2 or 3, place your IMCA number or certificate of selfinsurance number in the policy number area on the front of this form. If qualified under 4, place the word "BOND" in the insurance company name area on the front of this form. Falsification of this information will subject you to a jail term of up to two (2) years, a fine of up to $10,000 and suspension of your driver's license for a period of up to one year. SECTION 3 Line 16: Enter the year for the Mileage Reporting Period the miles are being reported. Line 17: Submit a Schedule G with a detailed "Plan of Operation". The Schedule BN must be signed by the responsible person. Please include the job title and date. Print or type the full name of your insurance company (not the agency or the group). Enter your policy number, and all the additional information requested. Effective January 1, 1983, Indiana law requires every Motor Vehicle registered in the State of Indiana to have proof of Financial Responsibility. Proof of Financial Responsibility includes one of the following: 1. Motor vehicle's insurance policy 2. Self insurance (certificate from BMV required) 3. Indiana Motor Carrier Authority Number (IMCA) (PSCI) 4. $40,000 in securities or cash deposited with the Treasurer of Indiana American LegalNet, Inc. www.FormsWorkFlow.com
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