Fillable 4442 IFTA Application

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4442 IFTA Application

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The 4442 IFTA Application form is 1 page long and contains:

  • 0 signatures
  • 26 check-boxes
  • 21 other fields

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File type: PDF

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1
IFTA APPLICATION
GENERAL INFORMATION
REGISTRATION YEAR
FEIN/SSN
LEGAL NAME
DOING BUSINESS AS (DBA) NAME
BUSINESS ADDRESS (Street or Road Designation)
CITY
STATE
ZIP CODE
MAILING ADDRESS – (Street or PO Box)
CITY
STATE
ZIP CODE
PERSON TO CONTACT
FAX NO.
E-MAIL ADDRESS
DECALS
NUMBER OF VEHICLES NEEDING DECALS:
***THERE IS NO CHARGE FOR DECALS***
The number of decals issued must reconcile with the number of trucks licensed, and will be subject to audit.
BULK STORAGE
DO YOU MAINTAIN BULK STORAGE?
YES NO If yes, where?
FUEL TYPE
TYPE OF FUEL USED:
GAS DIESEL PROPANE GASOHOL ETHANOL METHANOL
CNG LNG E-85 M-85 A55
LICENSE TYPE
TYPE OF MISSOURI LICENSE:
APPORTIONED BEYOND LOCAL FARM LOCAL DEALER
LEASE INFORMATION
ARE YOUR VEHICLES INVOLVED IN A LEASE AGREEMENT?
YES NO
If Yes, who is responsible for the fuel tax reporting? Lessor Lessee
Name and address of Lessee:
PREVIOUS IFTA
HAVE YOU PREVIOUSLY HELD AN IFTA LICENSE IN ANOTHER JURISDICTION?
YES NO
If yes, in what jurisdiction? Is that license currently suspended or revoked? YES NO
SIGNATURE
SIGNATURE
DATE
MISSOURI DEPARTMENT OF TRANSPORTATION
E-MAIL
contactmcs@modot.mo.gov
MOTOR CARRIER SERVICES
PHONE
1.866.831.6277
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270
FAX
573.751.0916
2
IFTA APPLICATION INSTRUCTIONS
SECTION 1. GENERAL INFORMATION
Registration Year – Enter all four digits of the registration year.
FEIN/SSN – Enter the Federal Employee Identification Number issued by the Internal Revenue Service. A sole proprietor who does
not have an FEIN should enter a Social Security Number.
Legal Name – Enter the company’s legal name. This name must be the same as what is registered with the FMCSA. Do not enter a
DBA name.
Single Owner: enter the first and last name as shown on birth records.
Partnership: list the legal name of each partner.
Corporation or LLC: enter the unique name that is on file with the company’s state of incorporation.
Doing Business As (DBA) Name – If the company uses a fictitious (DBA) name, and is a Missouri based carrier, that name must be
registered with the Missouri Secretary of State. Contact the Secretary of State’s office at 1.800.223.6535 with questions.
Business Address – Enter the Missouri address where the registrant/motor carrier has an established place of business.
Mailing Address – Enter the mailing address, if different than the business address. This address may be a PO Box.
Person to Contact – Enter the name of the person who will be the contact for the account.
Phone & Fax Numbers - Enter the business telephone and fax numbers of the contact person.
E-mail Address – Enter the e-mail address of the contact person for account correspondence.
SECTION 2. DECALS
Number of vehicles needing decals – Enter the number of qualified vehicles needing decals. (The number of decals issued must
reconcile with the number of trucks licensed, and will be subject to audit.)
SECTION 3. BULK STORAGE
Do you maintain bulk storage – Check the box to indicate if the company maintains bulk storage. If yes, indicate the location of the
bulk storage facility.
SECTION 4. FUEL TYPE
Type of fuel used - Check the box to indicate the type of fuel used in qualified vehicle(s).
SECTION 5. LICENSE TYPE
Type of Missouri license – Indicate the type of Missouri license plate(s) that are displayed on the qualified vehicle(s).
SECTION 6. LEASE INFORMATION
Leased Vehicles – Check the box to indicate if the vehicle(s) being licensed are leased. If yes, indicate who is responsible for the fuel
reporting and the name and address of the party the vehicle(s) are leased to.
SECTION 7. PREVIOUS IFTA
Previously held IFTA License – Check the box to indicate if the company has previously held an IFTA license in another jurisdiction. If
yes, check the box to indicate if the license has been suspended or revoked and the jurisdiction in which the license was held.
SECTION 8. SIGNATURE
The signature on the application shall be considered the signature to your unsigned quarterly returns for the registration year and
will become part of your quarterly returns. Signing the application also certifies that you understand the requirements of the
International Fuel Tax Agreement and that all information supplied on the application and quarterly returns will be true, correct and
complete to the best of your knowledge.
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4442 IFTA Application

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Completed 20 July 2020

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