Form Mcsa 5889 – Fill Out and Use This PDF

Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire. For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division.

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0060. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

Name and address changes and reinstatements of operating authority can be requested on our web site at https://li-public.fmcsa.dot.gov/LIVIEW/PKG_ REGISTRATION.prc_option (supporting documents must be submitted separately). You may submit this form to the above address, via our web form at https://ask. fmcsa.dot.gov/app/ask, or fax it to 202-366-3477. There is no fee for an address change, but name changes cost $14 and reinstatements $80. For more assistance with these transactions and other Registration, Licensing and Insurance functions (including transfers of operating authority), see the FAQs at https://ask.fmcsa.dot.gov.

Please submit all the requested data in Section A as represented in your current USDOT records. Changes can be indicated in Section B for address changes, Section C for name changes, and Section D for Reinstatements. Credit card information can be submitted in Section E. Any partially-submitted data will be kept for 30 days. If the rest of the information is not submitted within that time, the submitted data will be discarded. FMCSA cannot make any changes until all required data is supplied.

ADDRESSES (as currently listed in FMCSA systems):

AFFILIATION WITH FMCSA-LICENSED ENTITIES OR OTHER APPLICANTS APPLYING FOR USDOT NUMBER REGISTRATION

Do you currently have, or have you had within the last three years of the date of this application, relationships involving common stock, common ownership, common management, common control or familial relationships with any FMCSA-regulated entities?

Yes No

If yes, provide the name of the company, USDOT Number, MC/FF/MX Number, and the company’s latest USDOT safety rating.

Applicant must indicate whether these entities are currently disqualified from operating commercial motor vehicles anywhere in the United States pursuant to section 219 of the Motor Carrier Safety Improvement Act of 1999 (MCSIA) (Public Law 106-159, 113 Stat. 1748 (Dec. 9, 1999)).

*These are required fields.

APPLICANT’S OATH

I verify under penalty of perjury, under the laws of the United States of America, that all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualified and authorized to file this application. I know that willful misstatements or omissions of material facts constitute Federal criminal violations punishable under 18 U.S.C. § 1001 by imprisonment of up to 5 years and fines up to $250,000 for each offense.

Additionally these statements are punishable as perjury under 18 U.S.C. § 1621, which provides for fines of up to $250,000 or imprisonment of up to 5 years for each offense.

I further certify under penalty of perjury, under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or State offense involving the distribution of possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits, either by court order or operation of law, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, formerly Pub. L. 100-690, Title V, Section 5301, Nov. 18, 1988, 102 Stat. 4310, renumbered and amended Pub. L. 101-647, Title X, Section 1002 (d), Nov. 29, 1990, 104 Stat. 4827 (21 U.S.C. 862).

Check if new physical and mailing addresses are the same. Otherwise, complete mailing address information below.

IS THERE ANY CHANGE IN OWNERSHIP, MANAGEMENT, OR CONTROL OF THE COMPANY? ARE YOU A MEXICAN CARRIER?

I am making one of the following changes which does not require a transfer (select one) but does require documentation (include with form submission):

FORM MCSA-5889 • Page 2 of 3

I WOULD LIKE TO REINSTATE THE FOLLOWING AUTHORITY(s):

PLEASE CHECK THE BOX TO INDICATE YOUR ASSENT TO THIS STATEMENT:

I understand that reinstatements may not be processed immediately. It is the responsibility of the motor carrier to ensure that they are in full compliance with all FMCSA regulations prior to beginning interstate operations. Authority will not be reinstated until BOC-3 Form (Designation of Process Agent) and required insurance are on file. More instructions can be found at http://www.fmcsa.dot.gov/registration/insurance-requirements.

and CHECK ONE OF THE FOLLOWING OPTIONS:

I authorize the Federal Motor Carrier Safety Administration to reinstate the operating authority of the Motor Carrier/Broker/Freight Forwarder identified above. I understand that the credit card below will be charged $80, and that this Authorization will be stored electronically with the credit card number obscured, except for the last four numbers.

I authorize the Federal Motor Carrier Safety Administration to reinstate the operating authority of the Motor Carrier/Broker/Freight Forwarder identified above. I have attached payment of $80 in the form of a check or money order, payable to FMCSA, to the address in section E.

Pursuant to 49 CFR 360.3(c), fees are not refundable. After the application or document has been accepted for filing by the FMCSA, the filing fee will not be refunded, regardless of whether the document is granted or approved, denied, rejected, dismissed or withdrawn.

Montana