Form Com Mft 104 PDF Details

Form COM-MFT 104 is a form that is used to request an exemption from the one year waiting period for reapplication after termination of MFT services. This form may be used by individuals who have been terminated from MFT services due to circumstances beyond their control.Circumstances that are typically beyond the individual's control include, but are not limited to: death, relocation, or illness of the therapist. Use this form if you meet all of the requirements listed below and would like to apply for an exemption from the one year waiting period. You must also attach a letter explaining your situation in detail. Note: The exemptions granted under this form are discretionary and will be reviewed on a case-by-case basis. Form COM-MFT 104 is a form that can be used by individuals who have been terminated from MFT services due to circumstances beyond their control. Circumstances that are typically beyond the individual's control include, but are not limited to: death, relocation,

QuestionAnswer
Form NameForm Com Mft 104
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesMFT-104, IFTA/, Yesidentify, maryland ifta application

Form Preview Example

IFTA license application instructions:

State of Maryland

Comptroller of Maryland

Revenue Administration Division-Motor Fuel Tax

Maryland

License Application

for the

International Fuel Tax Agreement (IFTA)

Maryland is your base jurisdiction for IFTA licensing and reporting if:

Your IFTA account number with the Revenue

 

 

 

 

 

 

 

 

 

 

 

Administration Division will be your Federal

You have an established place of business in

Identification Number.

 

Maryland from which motor carrier operations

 

 

 

are performed;

 

 

 

 

 

 

Credentials are required for all “Qualified Motor

You

maintain

the

operational

control and

Vehicles.”

A “Qualified Motor Vehicle” means a

 

operational records for qualified motor

motor vehicle used, designed, or maintained for the

 

vehicles in Maryland or can make these

transportation of persons or property and:

 

records available in Maryland;

 

 

1) having 2 axles and a gross vehicle weight or

You

have

one

or

more

qualified

motor

 

vehicles based in Maryland for vehicle

a registered gross vehicle weight exceeding

 

registration purposes (registered with the

26,000 pounds;

 

Maryland Motor Vehicle Administration);

2) having 3 or more axles regardless of weight;

You

have

one

or

more

qualified

motor

 

vehicles which actually travel

on Maryland

or

 

 

 

 

highways; AND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3) used in combination when the weight of such

You

operate

in

at

least

one

other

IFTA

 

jurisdiction.

 

 

 

 

 

 

 

combination exceeds 26,000 pounds gross

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

vehicle weight or registered gross vehicle

The IFTA license

offers several benefits

to the

weight.

 

 

interstate/interjurisdictional

motor

carrier.

These

 

 

Exempt vehicles include recreational vehicles not

benefits include one set of credentials, one quarterly

tax report, which reflects the net tax or refund due,

used in any business endeavor and vehicles owned

and

one

audit in

most

circumstances.

These

by the United States government.

advantages all lead to cost and time savings for the

 

 

Maryland has adopted the International Fuel Tax

carrier. For operations in non-IFTA jurisdictions,

IFTA carriers must continue to follow the current

Agreement (IFTA). This is a base-state fuel tax

procedures and file the reports required by the

agreement that requires motor carriers based in

statutes and regulations of each non-IFTA

Maryland and operating in at least one other IFTA

jurisdiction.

 

 

 

 

 

 

 

 

member jurisdiction to obtain a Maryland IFTA

 

 

 

 

 

 

 

 

 

 

 

license and decals, which will be honored in all IFTA

You must register as an IFTA carrier if you

jurisdictions.

The motor carrier files one fuel tax

qualify.

If

you operate 100% of your miles in

report with Maryland on which operations in all IFTA

Maryland, you do not need to register as a

jurisdictions

are reported. All contiguous United

Maryland intrastate carrier provided those

States and Canadian provinces are members of

intrastate vehicles are tagged by the Maryland

IFTA.

 

Motor Vehicle Administration.

 

 

 

 

 

 

 

 

Exceptions are: Alaska; District of Columbia; and

Complete the attached application to apply for

the Northwest, Nunavut and Yukon Territories of

your IFTA license and decals.

 

 

 

Canada. If you plan to operate in any of these

 

 

 

 

 

 

 

 

 

 

 

jurisdictions, you must contact them individually for

 

 

 

 

 

 

 

 

 

 

 

instructions.

 

 

 

 

 

 

 

 

 

 

 

 

COM/MFT-104 Rev. 7/12

 

 

License Application

 

State of Maryland

 

 

 

Comptroller of Maryland

 

 

For the International Fuel Tax

 

 

Motor Fuel Tax

 

 

 

Agreement (IFTA)

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Is the qualified vehicle tagged in Maryland?

 

6. Contact person who will complete your IFTA

 

 

 

 

 

 

quarterly reports.

 

 

Yes

No—tagged in _______________

 

 

 

 

 

 

 

 

 

 

Name: __________________________________________

 

Do the Maryland tagged qualified vehicles travel

 

 

 

 

 

100% of their miles in Maryland?

 

Telephone number: (_____) _________________________

 

______ No—Complete entire application

 

Fax number:

(_____) _________________________

 

______ Yes—You do not qualify for an IFTA License

 

 

 

 

 

 

 

 

 

 

E-mail address: ___________________________________

 

 

 

 

 

 

 

 

2. Applicant’s name and location address:

 

7. Type of ownership:

 

 

Applicant’s full legal name:

 

_______

Individual

______ Partnership

 

 

 

 

 

 

_______ Corporation

______ Government

 

 

 

 

 

 

 

 

(state or local)

 

Trade name (if different from legal name):

 

_______

Other (please identify)

 

 

 

 

 

 

______________________________________________

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Complete for partners, corporation officers or

 

 

 

 

 

 

members:

 

 

 

 

 

 

 

Name/Title: ________________________________________

 

City: __________________ State: _____ Zip: ___________

 

 

 

 

 

 

 

(9-digit Zip)

 

Social Security Number:

_________________________

 

 

 

 

 

 

Telephone Number: (______) _____________________

 

 

 

 

 

 

 

3. Applicant’s Federal Employer’s Identification (EIN):

 

 

 

 

__ __ - __ __ __ __ __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

Name/Title: _______________________________________

 

 

AND

 

 

 

 

 

Applicant’s Social Security Number (SSN):

 

Social Security Number: _________________________

 

 

 

 

 

__ __ __ - __ __ - __ __ __ __

 

 

 

Telephone Number: (______) ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Mailing address (if different from your location address).

 

Name/Title: _______________________________________

 

All tax reports, decals and correspondence will be sent to

 

 

 

 

 

this address if you provide one.

 

Social Security Number: _________________________

 

Street: __________________________________________

 

Telephone Number: (______) ____________________

 

 

 

 

 

 

City: _____________________State ______ Zip _________

 

 

 

 

 

 

 

 

 

 

 

(9-digit Zip)

 

 

 

 

 

 

 

 

 

 

Name/Title: _______________________________________

 

 

 

 

 

Social Security Number:

________________________

 

5. US DOT # __________________________________

 

 

International Registration Plan (IRP) Account #: __________

 

Telephone Number: (______) ____________________

 

 

 

 

 

 

 

 

 

Check here only if you have non-apportioned tags: ________

 

 

 

 

 

 

 

 

 

 

 

 

 

COM/MFT-104 REV. 7/12

9.Location of records for audit purposes:

______ Same as location address

______ Same as mailing address

______ Other—show name and address with 9-digit zip code

10.Is the qualified vehicle(s) tagged in the exact legal name as it appears in response to question #2 of this application?

Yes No --tagged in the name of:

_______________________________________________

A copy of your lease agreement may be requested before your application can be approved.

My lease is with:

Name __________________________________________

Address _________________________________________

City _________________ State______ Zip ____________

Telephone (______) _______________________________

Fax (______) _______________________________

Applicant agrees to provide the Comptroller of Maryland a copy of the lease agreement upon request.

11.A set of decals will be issued for each qualified motor vehicle and one license will be issued per licensee. A photocopy of this license must be carried in each vehicle displaying decals.

How many of your vehicles need decals? ______________

12. Type(s) of fuel consumed by qualified motor vehicle(s)

 

______

Diesel/kero

______

Gasohol

______

Gasoline

 

 

 

 

 

______

Natural Gas (CNG or LNG)

______

Propane (LPG)

13. Do you store fuel in any IFTA jurisdiction?

No Yes—Identify the state/province where you store fuel

Fuel ______________

Where ________________________

Fuel ______________

Where ________________________

Fuel ______________

Where ________________________

Fuel ______________

Where ________________________

14.Have you had an IFTA License that was suspended or revoked in any state/province?

No Yes—identify the jurisdiction(s):

________________________ ______________________

________________________ ______________________

15. Certification by all applicants

The IFTA applicant agrees to comply with the reporting, payment, record keeping and license display requirement as specified in the International Fuel Tax Agreement. The applicant further agrees that Maryland may withhold any refunds due if the applicant is delinquent on payment of fuel taxes due to any member jurisdiction. Failure to comply with these provisions shall be grounds for revocation of the license and operating authority in all member jurisdictions.

The IFTA applicant further, specifically:

Acknowledges that the RAD provides an electronic copy of the IFTA Compliance Manual on the Comptroller of Maryland’s website, and if the applicant has no access to that source, that on request, the RAD will provide a printed copy.

Agrees to maintain a record of fuel purchased and miles traveled within each jurisdiction, by each vehicle.

Until such time as the District of Columbia is accepted as a member of IFTA, Maryland based IFTA licensees requesting a refund for fuel used in a non-IFTA jurisdiction, will not automatically be issued the refund. These licensees may be required to submit copies of all mileage and fueling records to support the claim prior to payment.

Applicant agrees, under penalty of perjury, that the information given on this application is, to the best of his/her knowledge, true, accurate and complete.

This form must be signed by an owner, partner, member or corporate officer listed on this application, or by an authorized agent.

Printed name____________________________________

Signature _______________________________________

Title ___________________________________________

Date ___________________________________________

Mail application to:

Comptroller of Maryland

Revenue Administration Division

IFTA Program

PO Box 2999

Annapolis, MD 21404-2999

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Yesidentify writing process described (stage 1)

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Applicants name and location, Mailing address if different from, and NameTitle Social Security Number in Yesidentify

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Yesidentify writing process described (part 5)

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