Form Mfut 12 – Fill Out and Use This PDF

Illinois Department of Revenue

MFUT-12 ApplicationforMotorFuelUseTax

IFTA License and Decals

1	FEIN/SSN _____________________________________		3	IRP no.	___________________________________
		Federal employer identification number/Social Security number			Illinois international registration plan firm number
2	IBTno.	_____________________________________	4	US DOT no.	___________________________________
		Illinois business tax number (if applicable)			United States Department of Transportation number

Step 2: Check your application type (Check all that apply.)

5 ___ Original application	___ Ordering additional or replacement decals
___ Renewal application	___ Correcting account information

Step 3: Identifyyourbusiness

6Write your business’ name and address. A physical address is required. Post Office box numbers will not be accepted.

Legal name: ____________________________________ Trade(DBA)name:__________________________________

Street address:______________________________________________________________________________________

Number and street (required)

_________________________________________________________________________________________________

City	State	ZIP	Country
Contact person: _________________________________		Telephone: (_____)______ - ___________

7Write the name and mailing address where you want your tax returns sent (if different than Line 6). If the name is different than Line 6, a power of attorney form must also be attached. Name:_____________________________________________________________________________________________

Mailing address:_____________________________________________________________________________________

Number and street (required)

_________________________________________________________________________________________________

City

State

ZIP

Country

8Write the name and mailing address where you want your decals sent (if different than Line 6).

Name:_____________________________________________________________________________________________

Mailing address:_____________________________________________________________________________________

Number and street are required. Post office boxes cannot be accepted.

_________________________________________________________________________________________________

City

State

ZIP

Country

Step 4: Complete your decal order

You must purchase and display one set of two decals for each of your qualified motor vehicles.

Step 5: Identify your type of operation

20	Check your type of business ownership.
	____ Individual ____ Corporation ____ Partnership ____ State/federal government		____ Non-profit organization
21	If you checked “Corporation,” write the date and state of incorporation.	__ __/__ __/__ __ __ __		______________
		Month Day	Year	State

22List the owners or corporate officers.

SocialSecurityno.

Name and title

City and state

__ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________

__ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________

__ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________

__ _ - _ _ - _ _ _ _ __________________________________________________ _______________________________

23 Do you currently have or have you ever had an IFTA license from a state other than Illinois? ____ yes ____ no

If you checked “yes,” tell us in what jurisdictions you were previously licensed. ____________________________________

Step 6: Tell us your fuel types, operations, and bulk fuel storage

24List the number of qualified motor vehicles you own or operate interstate________________________________________

25List the number of qualified motor vehicles you own or operate intrastate________________________________________

26Check the type of fuels used in the qualified motor vehicles you own or operate:

❒	Diesel	❒	Gasoline	❒	Gasohol	❒	LP gas	❒	Compressed natural gas
❒	Ethanol	❒	Methanol	❒	E-85	❒	M-85	❒	A-55

27List each jurisdiction in which you maintain bulk fuel storage. Attach additional sheets if necessary.

______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________
______________________	________________________	________________________	_______________________

Step 7: Signbelow

Your FEIN or SSN is used for account identification, payment processing, and record keeping. Your number and pertinent account information may be provided to IFTA jurisdictions, governmental and state agencies, and any persons necessary for administering the Motor Fuel Tax Law.

Underpenaltiesofperjury,IstatethatIhaveexaminedthisapplicationand,tothebestofmyknowledge,itistrue,correct,andcomplete.Theapplicant agreestocomplywithalllicensedisplay,recordkeeping,reporting,andpaymentrequirementsasspecifiedintheIllinoisMotorFuelTaxLawandthe InternationalFuelTaxAgreement.ApplicantfurtheragreesthattheIllinoisDepartmentofRevenuemaywithholdanyoverpaymentsdueifitisdelinquent onpaymentsofmotorfuelusetaxesduethestateofIllinoisoranyIFTAmemberjurisdiction.Applicantunderstandsthatfailuretocomplywiththese provisionsisgroundsforrevocationofitslicenseinallapplicablejurisdictions.

Note: Without proper signature from an owner, partner, authorized corporate officer, authorized agent, or employee who has the control, supervision, or responsibility of filing returns and making payment of the tax, your application will be denied.

_________________________________________________			Mail to:	MOTORFUELUSETAXSECTION
				ILLINOIS DEPARTMENT OF REVENUE
Signature
_______________________				POBOX19467
				SPRINGFIELD IL 62794-9467
Title
(_____) _____ - _________	__ __/__ __/__ __ __ __			Telephone: 217 785-1397
Telephone	Month Day	Year