1a This application is for calendar year 1b Reason for application
New Additional license
Renewal Additional decals
2 Identication Employer identication number
Sux, if any
Social Security number
number
OR SS
3 Type of business
Sole proprietor/individual Corporation Partnership LLC/LLP Other:
4 Legal name of business 5 USDOT number
6 Doing business as (DBA) name (if dierent from legal name) 7 Business phone number
( )
8 Physical address (number and street) 9
Mailing address
(if dierent than physical address; number and street or PO box)
City State ZIP code City State ZIP code
10 Will you be traveling outside New York State? 11 Are you registered for New York State highway use tax? 12 IRP registration number
Yes No Yes No If No, see instructions
13 Have you ever had an IFTA license from a state other than New York?
Yes No If Yes, list state(s):
14 Do you have bulk fuel storage?
Yes No If Yes, list in which state(s):
IFTA-21
(9/21)
For mailing instructions, see Form IFTA-21-I, Instructions for Form IFTA-21.
Department of Taxation and Finance
New York State International Fuel
Tax Agreement (IFTA) Application
15 Number of IFTA vehicles:
x $8 per set of 2 decals
(see instructions) = ...... 15 .00
16 Additional license ($2 fee; mark an X in the box if needed) and enter 2 on line 16 ......... 16 .00
17 Total due (add lines 15 and 16; see below for how to pay) ....................................................... 17 .00
• Pay the fees (total due) • Make check or money order payable in U.S. funds
with this application to: Commissioner of Taxation and Finance
Decal order
For oce use only
$ Number
Deposit number
Certication: The applicant agrees to comply with reporting, payment, recordkeeping, and license-display requirements as specied in the New York
State Tax Law and the International Fuel Tax Agreement. The applicant further agrees that New York State may withhold any refunds due if the IFTA
applicant is delinquent on payment of fuel taxes due to any IFTA member jurisdiction. Failure to comply with these provisions shall be grounds for
revocation of any IFTA license in all member jurisdictions.
I certify with my signature that to the best of my knowledge and belief, the information on this application is true, correct, and complete. I understand
that any falsication may subject me to civil and criminal sanctions found in Tax Law § 1815, and Penal Law §§ 175.35 and 210.45.
Type or print name of person signing Title
Email address of person signing
Signature of owner, partner, member, ocer, or person authorized by attached Power of Attorney Telephone number
(with area code) Date signed
( )
