Ap 178 Form – Fill Out and Use This PDF

Item 1 - Sole owner: Enter the irst name, middle initial and last name.

Partnership: Enter the legal name of the partnership.

Corporation, limited liability company, association: Enter the legal name exactly as it is registered with the Secretary of State.

Other legal entity: Enter the title of the organization.

Item 2 - Enter complete mailing address where you wish to receive mail from the Comptroller of Public Accounts. If you wish to receive mail at a different address for other taxes, attach a letter with the other addresses.

Item 4 - Enter the nine-digit FEIN assigned to your entity by the Internal Revenue Service.

Item 7 - If you have an eleven-digit Texas taxpayer number for reporting another type of tax, enter that number. (You can also enter in your Texas vendor identiication number.)

Item 8 - Ownership: Check the appropriate box by the type of organization.

Item 9 - Texas Entity: Enter the ile number assigned by the Secretary of State and the ile date.

Item 10 - Foreign Entity (chartered outside of Texas): Enter the state or country of formation, the charter/ile number and the Texas Secretary of State ile number and date.

Item 11 - Limited Partnership: Enter the state in which the partnership is registered and the identiication number.

Item 12 - Partnership: Enter information for all partners.

Corporation or Other Organization: Enter the information for the principal oficers (president, vice-president, secretary). If the applicant does not have a Social Security number, enter the Individual Taxpayer Identiication Number (ITIN) or other number assigned by the federal government for use when iling federal income tax returns.

Item19- Enter the actual physical address of your business. Do not use a P.O. Boxorruralroutenumber.Ifmorethanonelocation,attachaseparatesheet.

Item 23 - Do not complete this application if you have a written lease agreement in your iles that clearly states the lessor is responsible for iling your Texas IFTA reports.

If the lease agreement does not clearly state who is responsible for iling Texas IFTA reports, the reporting responsibility defaults to the owner of the vehicle (lessor).

Item 26 - Effective date of the IFTA license cannot be prior to the date the IFTA application is received.

Item 30 - Check the appropriate block(s). You must identify each fuel type used.

Item31- Check each jurisdiction in which you operate a qualiied motor vehicle.

DEFINITIONS:

Qualiied Motor Vehicle means a vehicle registered in Texas –

•with two axles and registered gross vehicle weight (GVW) exceeding 26,000 pounds; or

•having three or more axles; or

•used in combination when the registered GVW exceeds 26,000 pounds.

Qualiied Motor Vehicle does not include recreational vehicles.

Recreational Vehicle means vehicles such as motor homes, pickup trucks with attached campers, and buses when used exclusively for personal pleasure by individuals. The vehicle may not be used in connection with any business endeavor.

Registration means the qualiication of motor vehicles normally asso- ciated with a prepayment of license plate and registration card or temporary registration containing owner and vehicle data.

Base Jurisdiction means the jurisdiction where qualiied motor vehicles are based for vehicle registration purposes and where the operational control and records of the qualiied motor vehicles are maintained or can be made available.

AP-178-2 (REV.6-18/17)

Texas Application for International Fuel Tax Agreement (IFTA) License

• Please read instructions.

• Type or print.

*AP17820W061817*

*AP17820W061817*

* A P 1 7 8 2 0 W 0 6 1 8 1 7 *

Page 1

• Do not write in shaded areas.

IDENTIFICATION

1.Legal name of owner (Sole owner, partnership, corporation, limited liability company, association or other legal entity)

•

2.Mailing address (Street and number, P.O. Box or rural route and box number)

•

City

State

ZIP code

County

•

•

•

3. Enter the name and daytime phone number of the person primarily responsible for iling tax returns

•

Enter the email address of this person

TAXPAYER

4.Enter your Federal Employer Identiication Number (FEIN), if any,

assigned to the owner entered in Item 1 .......................................................................................

5.Enter your Social Security number (SSN) if you are a sole owner ...................................................

6. Check here if you do not have either FEIN or SSN.

7.Enter your taxpayer number for reporting any Texas tax OR your Texas

vendor identiication number if you now have or have ever had one ................................................

1

3

OWNERSHIP

PROPRIETORS

SUCCESSOR INFORMATION

8. Indicate how your business is owned.

Sole owner

Partnership

Texas entity

Trust

(Submit a copy of trust agreement

with application.)

Foreign corporation

Limited partnership

Other (explain)

9. If your business is a Texas entity,

File number

File date

enter the ile number and date

10. If your business is a foreign entity, enter the state or country of formation, charter/ile number, Texas Secretary of State ile number and date.

	State/country of formation		Charter/ile number			Texas Secretary of State ile number				File date
11. If your business is a limited partnership, enter the home state,				Home state				Partnership date		Identiication number
the partnership date and identiication number

12. List all general partners or principal oficers of your business. (Attach additional sheets, if necessary.) If you are a sole owner, skip Item 12.

Name (First, middle initial, last)

SSN or ITIN

Title

•

•

Home address (Street and number, city, state, ZIP code)

Phone (Area code and number)

Name (First, middle initial, last)

SSN or ITIN

Title

•

•

Home address (Street and number, city, state, ZIP code)

Phone (Area code and number)

Name (First, middle initial, last)

SSN or ITIN

Title

•

•

Home address (Street and number, city, state, ZIP code)

Phone (Area code and number)

If you purchased an existing business or business assets, complete Items 13-16. If you did not, skip to Item 17.

13. Enter the former owner's trade name. If known, enter the former owner's Texas taxpayer number.

Trade name

Taxpayer number of former owner

14. Enter the former owner's legal name. If known, enter the former owner's address and telephone number.

Legal name of former owner		Phone (Area code and number)

Address of former owner (Street and number, city, state, ZIP code)

15. Check each of the following items you purchased.

Inventory

Corporate stock

Equipment

Real estate

Other assets

16. Enter the purchase price of the business or assets purchased and the date of purchase.

Purchase price

Date of purchase

$

BUSINESS INFO.

LICENSE INFORMATION

18. Trade name (Actual name under which your business operates)

Business number (Area code and number)

•

19.Location of your business (Use street and number - NOT P.O. Box or Rural Route)

City

State

ZIP code

County

20.Name of bank or other inancial institution (Attach additional sheets, if necessary.)

Business Personal

21. List Texas Apportioned License Cab Card account number from the Texas Department of Motor Vehicles	•
22. If you do not have a Texas Apportioned License Cab Card account number,	•
list your Texas license plate number
23. If you do not have a Texas Apportioned License Cab Card account number or a Texas license plate number,
is your qualiied motor vehicle leased? (Submit a copy of lease agreement with the application)		•		YES		NO

If “YES,” does your lease agreement specify that you are the responsible party for iling reports and paying the fuel tax?

..........................................................................................(See speciic instructions for information about lease agreements.)

•

YES

NO

24. List your U.S. DOT number

•

25. Are you in a lease agreement and operating under another carrier's U.S. DOT number?

•

YES

NO

If "YES", please list carrier's name and U.S. DOT Number

•

Name

•

DOT Number

26. Requested effective date for IFTA license (see speciic instructions for information

•

Month

Day

Year

regarding effective date for IFTA license)

..........................................................................................................

27. IFTA decals will be issued for each of your qualiied motor vehicles. Enter the number of motor vehicles requiring decals

28. Have you ever been issued an IFTA license from a jurisdiction other than Texas?

•

YES

NO

If "YES," please list those jurisdictions and the year licensed

..............................................29. Has your IFTA license ever been suspended or revoked by a jurisdiction other than Texas?

•

YES

NO

If "YES," please list those jurisdictions

30. Types of fuels used by your qualiied motor vehicles (Check all that apply):

01 - Diesel

02 - Gasoline

03 - Ethanol

04 - Propane

•

05 - CNG

06 - A-55

07 - E-85

08 - M-85

09 - Gasohol

10 - LNG

11 - Methanol

12 - Biodiesel

13 - Electricity

14 - Hydrogen

31. Indicate with a check () the jurisdictions in which you are operating, and in which you maintain bulk fuel storage (OP-Operate; BF-Bulk Fuel Storage)

O P BF

OP BF

OP BF

OP BF

AL	Alabama
AK	Alaska
AZ	Arizona
AR	Arkansas
CA	California
CO	Colorado
CT	Connecticut
DE	Delaware
DC	Dist. of Columbia
FL	Florida
GA	Georgia
ID	Idaho
IL	Illinois
IN	Indiana
IA	Iowa
KS	Kansas

KY	Kentucky
LA	Louisiana
ME	Maine
MD	Maryland
MA	Massachusetts
MI	Michigan
MN	Minnesota
MS	Mississippi
MO	Missouri
MT	Montana
NE	Nebraska
NV	Nevada
NH	New Hampshire
NJ	New Jersey
NM	New Mexico
NY	New York

NC	North Carolina
ND	North Dakota
OH	Ohio
OK	Oklahoma
OR	Oregon
PA	Pennsylvania
RI	Rhode Island
SC	South Carolina
SD	South Dakota
TN	Tennessee
TX	Texas
UT	Utah
VT	Vermont
VA	Virginia
WA	Washington
WV	West Virginia

WI	Wisconsin
WY Wyoming
CANADIAN PROVINCES
AB	Alberta
BC	British Columbia
MB	Manitoba
NB	New Brunswick
NF	Newfoundland
NT	Northwest Territories
NS	Nova Scotia
NU	Nunavut
ON	Ontario
PE	Prince Edward Island
QC	Quebec
SK	Saskatchewan
YT	Yukon

REPRESENTATIVE

SIGNATURES

33. Legal name of authorized agent/representative

•

34. Mailing address

City

State

ZIP code

Business number (Area code and number)

35. The sole owner, all general partners, corporation president, vice-president, secretary or treasurer or an autho-

Date of application

Month

Day

Year

rized agent must sign this application. Representatives must submit a written power of attorney with application.

(Attach additional sheets if necessary.)

Bonds are not generally required of irst-time applicants. However, a bond may be required if an IFTA licensee has a history of not iling tax returns on time, not remitting tax due or other problems severe enough to indicate that a bond is required to protect the interests of all member jurisdictions.

The applicant agrees to comply with reporting, payment, record keeping and license and decal display requirements as speciied in the Interna- tional Fuel Tax Agreement. The applicant further agrees that Texas may withhold any refunds due if applicant is delinquent on payment of fuel taxes due any member jurisdiction. Failure to comply with these provisions shall be grounds for revocation of license in all member jurisdictions.

I (We) certify that the information in this document and any attachment is true, accurate and complete to the best of my (our) knowledge. I (We) acknowledge that any falsiication of document information subjects me (us) to civil and/or criminal sanctions of the state of Texas.

Type or print name and title of sole owner, partner, oficer or authorized agent

Type or print name and title of partner or oficer

Type or print name and title of partner or oficer

Sole owner, partner, oficer or authorized agent

Partner or oficer

Partner or oficer