Michigan Department of Treasury
5224 (11-14)
Michigan IFTA Service/Licensing Agency Application
INSTRUCTIONS: Complete all required elds below. Sign the application
before submitting to the fax or mailing address listed below. Please allow
30 days for processing.
* 1. Type of Tax Identication Number being used (Check ONLY ONE)
Social Security Number (SSN)
* Required Fields Federal Employer Identication Number (EIN)
* 3. Type of Business Ownership (Check ONLY ONE)
* 2. SSN or EIN
Owner/Operator (Individual) Limited Liability Corporation (LLC)
*4.a Business Telephone Number *Phone Country
Corporation Limited Liability Corporation (LLP)
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Partnership Religious
4.b Business Fax Number Phone Country
Non-Prot Corporation
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* 5. Complete Company Name (include, if applicable, Corp., Inc., P.C., L.L.C., etc.) 7.a Primary Contact Person
6. Assumed Name or DBA (if used) * 7.b Primary Phone Phone Country
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* 8. Mailing Address (Number and Street) * 7.c Primary E-Mail
City, State, ZIP Code Country
* 10. Do you currently manage any licensed Michigan IFTA accounts?
Yes No
* 9. Physical Address (Do NOT include P.O. Box)
If Yes, please attach Treasury Form 151: Authorized Representative
Declaration (Power of Attorney) for each taxpayer you currently represent.
City, State, ZIP Code Country
* 11. Is the above listed entity (individual or company) currently licensed for IFTA in Michigan as a carrier?
Yes No
This form is a one-time application to set up the demographics of the service/licensing agency. Completion of this form is not necessary each time the
service/licensing agency requires access to a particular IFTA account. When this form is processed, the primary contact for the service/licensing agency
is notied by email verifying the Agency is approved for the next steps. Please attach Form 151: Authorized Representative Declaration (Power of
Attorney) for each company/individual you currently represent. The Form can be found on our website at www.michigan.gov/IFTA under the
“Search for Michigan Department of Treasury Tax Forms” link. Please fax completed forms to (517) 636-4593 or mail to:
Michigan Department of Treasury
Special Taxes Division – IFTA Unit
P.O. Box 30474
Lansing, MI 48909-7974
Please enter the Name and Telephone number of the person submitting this application.
* 12.a Name (Last, First, Middle Initial) * 12b Business Title
* 12.c Signature * 12.d Telephone Number
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