Application For Yard Tractor Permit {YT-1}

State Form 47692 (R3 / 7-13) YT-1 Form Application For Yard Tractor Permit Annual Permit Fee: $40 IFTA Motor Account Number IRP Account Number US DOT Number State Zip Code County Federal Identification or Social Security Number Taxpayer Identification Number Indiana Department of Revenue Company Name DBA Name Address City Telephone Number Address of Terminal Locations (Indiana Only) Terminal 1 Terminal 2 Terminal 3 Terminal 4 Address Address Address Address City City City City This Yard Tractor Permit is an annual permit and applies to all yard tractors operated by the named carrier. This permit is not transferable to another carrier. Under no circumstances does this permit allow the carrier to carry cargo or transport or draw a semitrailer or other vehicle under the permit. Yard tractor refers to a tractor that is used to move semitrailers around a terminal or a loading or spotting facility. Any person in violation of the strict authorization granted by the above requested permit may be subject to fines, impoundment of all vehicles in violation and revocation of all operating permits issued by the department. Please make Check or Money order payable to the Indiana Department of Revenue. Under penalty of perjury, I declare that I have examined this Yard Tractor application and to the best of my knowledge and belief it is true, correct and complete. I further declare that I will distribute the Yard Tractor permit issued to me by the Indiana Department of Revenue only in vehicles that I am operating or causing to be operated. Taxpayer or Authorized Agent Typed or Printed Name Date Signed Title Telephone Number You may submit the form by: Fax (317) 615-7310 Email IndianaIRP@dor.in.gov Mail Indiana Department of Revenue Motor Carrier Services - Attn: IRP Unit 7811 Milhouse Road, Suite M Indianapolis, IN 46241-9612 American LegalNet, Inc. www.FormsWorkFlow.com