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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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State Form 55550 (R8 / 2-16) INIRP-BN Form International Registration Plan New Account Schedule BN Indiana Department of Revenue Section 1 1. Registrant Name 2. Fleet Street Address 4. City 5. State 3. County 6. ZIP Code 7. Fleet Mailing Address 8. County 10. State 9. City 11. ZIP Code 12. IRP Account Number 14. New Account 13. Fleet Number Yes No 15. Type of Carrier (check only one) Private Carrier Exempt Commodity Carrier "For Hire" Carrier (Common Carrier) Household Goods Carrier Section 3 16. Please designate the appropriate year for the mileage reporting period of July 1, _______ through June 30, _______. 2,875 25 559 Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, com3,357 plete and correct, and I am providing proof of financial responsibility 603 prior to affixing my signature hereto. 2,921 10 I agree Jurisdiction X NR Mileage Jurisdiction X Mileage 10 AL Alabama 1,824 BC British Col. 1,484 CT Connecticut 225 FL Florida 1,470 ID Idaho 1,181 KY Kentucky 646 MB Manitoba 121 MI Michigan 2,440 MS Mississippi NR 10 NB New Bruns 177 NE Nebraska 110 NT Northwest T. 1,401 NS Nova Scotia 2,698 OH Ohio 243 OR Oregon 10 QC Quebec 2,090 SD S. Dakota 3,819 TX Texas 2,808 For Official Use Only 5,790 ______________________________________________________ Address of Insurance Company 1,524 IN Indiana Miles 724 NR Miles NR 10 Total Fleet Miles American LegalNet, Inc. www.FormsWorkFlow.com 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 MN Minnesota MT Montana NC N. Carolina NF Newfoundland NJ New Jersey NV Nevada OK Oklahoma PA Pennsylvania RI Rhode Island SK Saskatchewan UT Utah VT Vermont WI Wisconsin WY Wyoming X Mileage 41 *AK Alaska 1,650 AZ Arizona 5,925 CO Colorado 10 DE Delaware 4,234 IA Iowa 5,173 KS Kansas 1,529 MA Massachusetts 999 ME Maine 790 MO Missouri 410 MX Mexico 3,146 ND N. Dakota 10 NH N. Hampshire 2,108 NM New Mexico 941 NY New York 1,826 ON Ontario 5,918 PE Prince Ed. Is. 90 SC S. Carolina 13 TN Tennessee 1,025 VA Virginia 103 WA Washington 1,824 WV West Virginia 870 YT Yukon Terr. Yes No 2,546 ______________________________________________________ 1,816 Signature of Owner or Responsible Officer 10 ____________________________ 910 Title NR ________________________ Date 10 ______________________________________________________ 10 Name of Your Insurance Company 5,908 (not the agency or group) 1,491 __________________ 21 Policy Number 212 5,523 ______________________________________________________ __________________________________ Insurance Company Telephone Number Instructions for INIRP-BN 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.) Lines 2 through 6: Enter the FLEET street address if different from the Indiana business street address on Schedule A. Lines 7 through 11: Enter the fleet mailing address if different from the applicant mailing address on Schedule A. Each FLEET may have an independent mailing address where credentials or other correspondence regarding this FLEET are 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 a new account. Line 15: Enter the Type of Carrier. Check only one. Section 3 Line 16: Enter the year for the mileage reporting period for which the miles are being reported. Schedule BN must be signed by the responsible person. Please include the person's job title and the 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. 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 NOTE: If qualified under 2 or 3, place your IMCA number or certificate of self insurance 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 years, a fine of up to $10,000, and suspension of your driver's license for a period of up to one year. Section 2 Place an X in the column to the right of the jurisdiction(s) 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. American LegalNet, Inc. www.FormsWorkFlow.com
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