Florida Ifta Application Form – Fill Out and Use This PDF

FLHSMV

Division of Motorist Services

IFTA/CH

2900 Apalachee Parkway, MAIL STOP 62

Date

Bureau of Commercial Vehicle and Driver Services

Tallahassee, Florida 32399-0626

FLORIDA HIGHWAY SAFETY

INTERNATIONAL FUEL TAX AGREEMENT

LICENSE APPLICATION

1.

2.

BUSINESS NAME

FEDERAL EMPLOYER IDENTIFICATION NUMBER [FEIN]

3.

FL

BUSINESS PHYSICAL ADDRESS

CITY

COUNTY

STATE

ZIP CODE

4.

BUSINESS MAILING ADDRESS

CITY

STATE

ZIP CODE

5.

6.

BUSINESS TELEPHONE NUMBER

BUSINESS E-MAIL ADDRESS

7.

8.

BUSINESS CONTACT PERSON

CONTACT PERSON’S E-MAIL ADDRESS/TELEPHONE NUMBER

10.		11.
	BUSINESS DOT #		IRP ACCOUNT #

12.LIST ALL OWNERS, PARTNERS OR CORPORATE OFFICERS [ATTACH ADDITIONAL DOCUMENTATION AS NEEDED]

13. IF NO ACTIVE IRP ACCOUNT: INDICATE NUMBER OF VEHICLES THAT WILL OPERATE UNDER THIS LICENSE APPLICATION: AND PROVIDE THE VEHICLE INFORMATION LISTED BELOW FOR EACH VEHICLE. [ATTACH ADDITIONAL SHEETS AS NEEDED]

QUALIFIED MOTOR VEHICLE(S) CURRENTLY REGISTERED IN FLORIDA:
_________________________	FLORIDA LICENSE PLATE#	FLORIDA LICENSE PLATE #	FLORIDA LICENSE PLATE #
FLORIDA LICENSE PLATE#

QUALIFIED MOTOR VEHICLE(S) NOT CURRENTLY REGISTERED IN FLORIDA (copy of registration and lease agreement required):

Fuel Type:			Fuel Type:			Fuel Type:
Jurisdiction:			Jurisdiction:			Jurisdiction:

NOTE: THIS APPLICATION IS NOT COMPLETE WITHOUT A DECAL ORDER AND PAYMENT (SEE PAGE 2). Enter the number of IFTA decal sets needed ($4.00 per set, per vehicle). Enter total dollar amount of your order. The address for mailing payment and this application and/or order form is located at the top of this page. Once you have an established IFTA account, an authorized agent (with a Power of Attorney on file) may sign renewal and additional decal orders (with proof and payment) on your behalf.

15C-12.008	1
HSMV 85008 (REV 2/2021)

NUMBER OF VEHICLES REQUIRING IFTA DECALS
DECAL FEE PER VEHICLE
	X	$4.00
TOTAL ENCLOSED	$
(MAKE CHECK PAYABLE TO FLORIDA DIVISION OF MOTORIST SERVICES)

I, THE UNDERSIGNED APPLICANT (BUSINESS OWNER OR COMPANY OFFICER) UNDERSTAND THAT, UNDER PENALTY OF PERJURY, I DECLARE I HAVE EXAMINED THIS APPLICATION AND DECAL ORDER AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS CORRECT AND COMPLETE. I AGREE TO COMPLY WITH ALL TAX REPORTING, PAYMENT, RECORD-KEEPING, AND LICENSE DISPLAY REQUIREMENTS SPECIFIED IN THE INTERNATIONAL FUEL TAX AGREEMENT. I FURTHER AGREE THAT THE FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES MAY WITHHOLD ANY REFUNDS DUE ME IF I AM DELIINQUENT ON PAYMENT OF FUEL TAXES DUE ANY MEMBER JURISDICTION. I UNDERSTAND THAT FAILURE TO COMPLY WITH THESE PROVISIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF MY LICENSE IN ALL MEMBER JURISDICTIONS.

PRINTED NAME

TITLE

TELEPHONE # (REQUIRED)

APPLICATION INSTRUCTIONS

1.BUSINESS NAME – Print the name of the motor carrier business making application. If the name is other than an individual's name, attach a copy of the corporation papers or fictitious trade name papers filed with the Florida Secretary of State.

2.FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) – Print your business’s FEIN. Your FEIN should always be referenced when inquiring

on your account.

The following contact information is needed for the business that is making application for an IFTA license. If your business will be using authorized agents to manage your IFTA correspondence and shipment of credentials, you must submit a completed, signed, and notarized Power of Attorney (POA) form (HSMV 96440). Once this POA form is on file, any one of your authorized agents may submit a request to update the shipping address you would like used for your IFTA routine correspondence and credentials.

3.BUSINESS PHYSICAL ADDRESS – Enter the Florida physical location (address, city & zip) of your motor carrier business or office. Post office boxes or rented mail boxes are NOT acceptable.

4.BUSINESS MAILING ADDRESS – Enter the address, city, state & zip used by the business. This address cannot be the address of a service provider or permitting company.

5.BUSINESS TELEPHONE NUMBER – Enter the business telephone number, including area code.

6.BUSINESS E-MAIL ADDRESS – Enter the business e-mail address.

7.CONTACT PERSON – Enter name of internal company person to contact about this account (if not licensee/company officer, attach letter designating this company employee).

8.CONTACT PERSON’S E-MAIL ADDRESS – Enter the contact person’s e-mail address and telephone number.

9.TYPE OF BUSINESS OWNERSHIP – Specify the type of business you own. Other options are Limited Company, LTD Liability LTD Partnership, Limited Liability Partnership, Company Limited, Limited Partnership.

10.U.S. DOT NUMBER – Enter the U.S. DOT number of the business.

11.INTERNATIONAL REGISTRATION PLAN (IRP) ACCOUNT NUMBER – Enter your Florida IRP account number. If you do not have a Florida IRP account, you must provide VEHICLE INFORMATION for each vehicle in your fleet See #13, below.

12.OWNER, PARTNERS OR CORPORATE OFFICER’S NAME(S) – Print the name, home address, city, state & zip, title, and telephone number of every company officer. Attach additional pages to the application, as necessary.

13.VEHICLE INFORMATION – If you do not have a Florida IRP account, indicate the total number of qualified vehicles that will operate under this license application. Provide the license plate number of those vehicles that are registered in Florida and, for those vehicles registered out of state, the name, state of registration, and VIN (with attached proof). Attach additional pages to the application, as necessary.

14.Use a check mark to indicate whether you intend to consolidate ALL of your vehicles in Florida.

15.Use a check mark to indicate whether you have ever held an IFTA license in another jurisdiction and, if YES, indicate jurisdiction(s).

16.Use a check mark to indicate whether your IFTA license has ever been revoked.

17.Use a check mark to indicate whether you maintain bulk fuel tanks, and, if YES, indicate type of fuel stored and the jurisdiction where the bulk fuel tanks are located.

FOR OFFICIAL USE ONLY (WALK IN COUNTER)

DECAL #(S)
PRESENTED TO (PRINT NAME):
SIGNATURE OF RECIPIENT:	DATE: