Ma Irp Application – Fill Out and Use

Section C- Complete this section when opening a new account or amending information within this section

ACCOUNT INFORMATION

Business Type - Corporation Sole Proprietor Trust LLC LLP Non Profit Partnership Other ___________________________

TIN TYPE		SSN		FEIN	Number_____________________ Accountholder US DOT_________________

Account Legal Name _____________________________________________________________________________

DBA Name_____________________________________________________________________________________

Phone Number ______________________ Fax Number ___________________________

Physical Address _______________________________City __________________ Zip Code____________ (No PO Box)

Mailing Address (If Different) ______________________________ City _______________ Zip Code_____________

Primary Contact Name __________________________________ Email ___________________________________

Address ___________________________________ City ________________________ Zip code________________

Phone ____________________Fax ____________________

Additional Contact Name ______________________________ Email ____________________________________

Address _____________________________________ City _________________ Zip code_____________________

Phone ____________________ Fax ____________________

Section D- Complete this section if creating a fleet or if you are amending information within this section

FLEET INFORMATION

Apportioned Fleet Type:

Private

For-Hire

Is this a rental company?

Yes

No

If Rental Company, choose one:

Rental is less than 45 days

Rental is greater than or equal to 45 days

Use:

Standard

Household Goods -- If household goods, Service Representative name: ______________________

Does the carrier hold a WY Operating Authority Permit?

Yes

No

Have you been apportioned in any other Jurisdiction in the last 18 months?

No

Yes, Jurisdiction________

Will this fleet be composed entirely or primarily of vehicles in which you operated or exercised control over during the

previous registration period?		Yes		No	If YES, see next question
Did the vehicle accrue actual distance in any of the jurisdictions for which you are seeking apportion?							Yes		No

Fleet Name____________________________________ Service Representative_______________________________

Phone Number ________________________________ Fax Number ________________________________________

Physical Address _______________________________City __________________ Zip Code____________ (No PO Box)

Mailing Address (If Different) ______________________________ City _______________ Zip Code_______________

INSTRUCTIONS FOR VEHICLE EQUIPMENT LIST

A completed RMV1 form stamped by your insurance is also required when adding vehicles.

If you change the insurance company, garage location, color, gross weight, passengers, or seats field(s), you are required to submit a RMV-3 Form stamped by your insurance company.

**Action – Place an “A” in the action box if adding a vehicle. Place a "D" in the Action box if deleting the vehicle. Place a "C" in the Action box if changing any vehicle information.

*1- Indicate the weight of the EMPTY vehicle. *2- Please use TT for Truck Tractor, TK for Truck, TR for Tractor, RT for Road Tractor or BS for Bus. *3- This is the combined or Gross Weight of the vehicle. If a weight group does not exist for this weight, a new group will be created unless you indicate you would like this vehicle in a higher weight group. *4- Indicate if this vehicle travels less than 10,000 miles nationally. *5- If the unit pulls a trailer indicate the maximum number of trailer axles that will be pulled. *6- Indicate if the motor carrier responsible for the safety of this vehicle is expected to change during this registration year.

IMPORTANT ADDITIONAL INFORMATION

USDOT Numbers- Under the Performance and Registration Information Systems Management (PRISM) program, an applicant must have a valid USDOT number that is unique to their IRP Account. Multiple accounts may not be opened using the same USDOT number, and you may not open an account using a USDOT other than your own. For example, if you are working for a company that has an existing IRP account, that company must add your vehicle to their account, unless you choose to open an account using your own USDOT number.

Temporary CAB Cards- Temporary CAB cards will be limited to only certain transactions in MassIRP. A temporary CAB card will be available to carriers in good standing for adding jurisdictions, amending weight, adding a fleet to an existing account, processing a fleet to fleet transfer. A temporary CAB card will not be available, for example, if you are registering and titling a vehicle. The sales tax, title fees and registration fees must be paid in full prior to receiving credentials.

You may need to complete one or more of the following forms as part of your application:

•Schedule D - Estimated Distance Justification: This form must accompany your application if you entered estimated distance for jurisdictions that was not derived from the Estimated Distance Chart.

•Power of Attorney: Power of Attorney is required for each vehicle contained on your application that is not titled in your name. Power of Attorney is a notarized statement on company letterhead signed by an authorized representative.

•MCRS Authorization: If the MCRS listed for a vehicle is different from the vehicle owner, or the account holder, you must provide a lease agreement or notarized statement on company letterhead which authorizes the use of the USDOT number and Tax Identification Number (TIN). The Authorization must include the US DOT number and the TIN, and the length of time the owner is authorized to use the USDOT number and TIN.

Applications must be signed. Incomplete or illegible applications will be returned to the registrant without processing.

Section F - WEIGHT INFORMATION

Please list the weight you wish to appear on your CAB Card for each Jurisdiction in which you will travel.

Jurisdiction	Weight	Jurisdiction	Weight	Jurisdiction	Weight	Jurisdiction	Weight	Jurisdiction	Weight
Alberta		Iowa		Missouri		NW Territory		South Dakota
Alaska		Idaho		Mississippi		Nevada		Saskatchewan
Alabama		Illinois		Montana		New York		Tennessee
Arkansas		Indiana		Mexico		Nunavut		Texas
Arizona		Kansas		New Brunswick		Ohio		Utah
Brit. Columbia		Kentucky		North Carolina		Oklahoma		Virginia
California		Louisiana		North Dakota		Ontario		Vermont
Colorado		Massachusetts		Nebraska		Oregon		Washington
Connecticut		Manitoba		Newfoundland/Lab		Pennsylvania		Wisconsin
Dist Columbia		Maryland		New Hampshire		Pr Edward Isl.		West Virginia
Delaware		Maine		New Jersey		Quebec		Wyoming
Florida		Michigan		New Mexico		Rhode Island		Yukon
Georgia		Minnesota		Nova Scotia		South Carolina

Units listed on this application will be authorized to operate in the jurisdictions and at the weights listed above. The weight recorded above will appear on the CAB Card for all IRP Jurisdictions for the units listed. Use separate pages for any vehicles with a weight difference in any jurisdiction.

Section G- DISTANCE SCHEDULE

Place “A” for actual or “E” for estimated miles reported for the period of July 1 through June 30. List mileage in each jurisdiction in which this fleet will travel and you wish to have apportionment. If using the Estimated Distance Chart be sure it is for the current registration year. All other jurisdiction fields should be left blank.

A		DISTANCE	A		DISTANCE	A					DISTANCE
/	JURISDICTION		/	JURISDICTION		/	JURISDICTION
E			E			E
	Alberta			Manitoba				Oklahoma
	Alabama			Maryland				Ontario
	Arkansas			Maine				Oregon
	Arizona			Michigan				Pennsylvania
	British Columbia			Minnesota				Prince Edward Island
	California			Missouri				Quebec
	Colorado			Mississippi				Rhode Island
	Connecticut			Montana				South Carolina
	Dist of Columbia			New Brunswick				South Dakota
	Delaware			North Carolina				Saskatchewan
	Florida			North Dakota				Tennessee
	Georgia			Nebraska				Texas
	Iowa			New Hampshire				Utah
	Idaho			New Jersey				Virginia
	Illinois			Newfoundland & Lab				Vermont
	Indiana			New Mexico				Washington
	Kansas			Nova Scotia				Wisconsin
	Kentucky			Nevada				West Virginia
	Louisiana			New York				Wyoming
	Massachusetts			Ohio				TOTAL
								DISTANCE

I hereby certify under the penalties of perjury that there are no outstanding excise tax liabilities on the vehicle(s) listed that have been incurred by the applicant, any member of the applicant's immediate family who is a member of the applicant's household or the business partner of the applicant. I hereby further certify that all information contained in this application is true and correct to the best of my knowledge and belief. False statements are punishable by fine, imprisonment or both.

Authorized Accountholder Signature ________________________________________ Date________________

Printed Name _________________________________ Position (if company)_____________________________

Signature on this application by the applicant or authorized representative constitutes the applicant’s consent to have the information submitted as part of participation in IRP and verified through an audit performed by the Commonwealth of Massachusetts Registry of Motor Vehicles, the Department of Revenue, or their agents. Further, the applicant understands that the Registry of Motor Vehicles and the Department of Revenue may exchange the information obtained during an audit for purposes of enforcing the International Registration Plan (IRP) and the International Fuel Tax Agreement (IFTA).