MN Prorate Account Checklist Form PDF Details

Starting or managing a commercial fleet in Minnesota involves various steps, one of which includes navigating the MN Prorate Account Checklist form. This comprehensive form serves as a vital tool for operators looking to apply for an International Registration Plan (IRP) and/or International Fuel Tax Agreement (IFTA) prorate account. It not only aids in aligning with legal requirements but also ensures that all necessary recordkeeping and tax duties are met efficiently. The packet contains essential components like a Recordkeeping Fact Sheet, sample forms for ease of understanding, and detailed instructions on the application process. Applicants are guided through prerequisites such as obtaining a USDOT Number, FEIN, and completing specific forms including the IRP Minnesota Presence Affidavit and the IFTA License and Decals Application. Upon submission, the documents undergo review, and successful applicants are then required to apply in person, bringing all relevant forms and documents for final approval. Additionally, the checklist outlines the account closing process, emphasizing the importance of retaining operational records for a set period after closure and ensuring compliance with mileage recording and insurance laws. This introduction to the MN Prorate Account Checklist highlights its role not just as a formality but as a comprehensive guide for commercial operators to adhere to state and federal regulations, ensuring a smooth operation of their commercial fleet endeavors in Minnesota.

QuestionAnswer
Form NameMN Prorate Account Checklist Form
Form Length16 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min
Other namesNew Prorate Account Checklist Form, Form PS2234-03

Form Preview Example

New Prorate Account Checklist

Full Name (print):

Business Name (if any):

Office Use Only

Prorate Acct. #:

Daytime phone #

This packet contains a Recordkeeping Fact Sheet, sample recordkeeping forms, and the forms needed to apply for an International Registration Plan (IRP) and/or International Fuel Tax Agreement (IFTA) prorate account in Minnesota. If you have questions about the application process or completing the forms, call our office at (651) 205-4141 during business hours.

STEP 1 – Before you start the application process, make sure you have the following items (links to online resources are included for your information):

1.USDOT Number – obtain online at www.dot.gov

2.Federal Employer Identification Number (FEIN) – obtain online at www.irs.gov/businesses

3.Heavy Highway Vehicle Use Tax Return (HVUT) Form 2290 – www.irs.gov/formspubs

4.Proof of vehicle ownership (e.g., title)

5.Lease agreement, if applicable

STEP 2 – Complete these five forms:

1.IRP Minnesota Presence Affidavit, PS2230 and copies of supporting documents

2.New Prorate Applicant Questionnaire, PS2231

3.Estimated Mileage Worksheet, PS2232

4.Minnesota IRP Renewal/Supplement Application (Schedule A and B), PS2276

5.IFTA License and Decals Application, PS2261

Submit this checklist and forms by mail or in person to the address at the bottom of this checklist or fax to (651) 215-0027.

The forms and documents will be reviewed by our office. You will be contacted by phone with the results of the review (usually within four days).

STEP 3 If you receive approval from our office:

You must apply in person at our office or a Prorate Deputy Registrar’s office. Bring originals of all required forms and supporting documents – including this checklist. You will receive license plates and decals at that time.

For a list of office locations and contact information, go to www.mndriveinfo.org.

Account Closing Process – If it becomes necessary to close the Prorate account, you must:

1.Complete Minnesota IRP Renewal/Supplement Application and/or IFTA quarterly report;

2.Ensure that there are no outstanding tax liabilities;

3.Turn in plates, stickers, cab cards, and/or IFTA license and unused IFTA decals; and

4.Retain operational records for four years after the account is closed.

I hereby affirm that I received the Recordkeeping Fact Sheet. I understand the recordkeeping and mileage recording requirements imposed by the International Registration Plan (IRP) and agree to abide by the IRP/IFTA regulations. The operational records and any other pertinent information required by the base jurisdiction (Minnesota) are available upon request and will remain available for four years after the account is closed. The registrant is in compliance with the laws requiring insurance while operating motor vehicles upon public roads and will maintain the required insurance coverage.

Registrant/Authorized Signature: ___________________________________________ Date: ________________

(Power of Attorney form required for authorized third party/service bureau)

Accepted by: ________________________________________ Dep. No.: __________ Date: ________________

(Prorate Unit/Deputy Registrar)

PS2234-03 Rev. 7/2007

Minnesota Department of Public Safety Driver and Vehicle Services Division

445 Minnesota Street Saint Paul, Minnesota 55101-5188

Office: (651) 205-4141 or TTY: (651) 282-6555

IRP/IFTA Recordkeeping Requirements

JUST T HE FA C T S

The International Registration Plan (IRP) and International Fuel Tax Agreement (IFTA) are cooperative pro- grams to collect and distribute registration and fuel tax revenue between member states and Canadian prov- inces. The programs benefit carriers by consolidating licensing and reporting requirements through the base (home) state.

The maintenance of mileage and fuel records is a requirement of IRP and IFTA. Mileage and fuel records are needed to ensure proper tax distribution among jurisdictions. The carrier and driver are responsible for main- taining vehicle trip reports that record by state/province every mile driven and every gallon of fuel put into the licensed power unit.

This fact sheet outlines the IRP/IFTA recordkeeping and reporting requirements. Topics include:

Trip Reports

Fuel Records

Recaps (Mileage and Fuel Summaries)

Record Retention

Audit

Account Closing Process

Trip Reports

Fuel Records

A "Trip Report" (see sample form) is the source document completed by the driver that records in detail the vehicle miles traveled and fuel purchased. These reports are used when completing the annual IRP registration renewal and the quarterly IFTA fuel tax returns.

The IRP and IFTA programs require that the vehicle mileage and fuel trip report contain the following items:

1.Date of trip (start and end)

2.Trip origin and destination (destination is the further- most point from the trip origin)

3.Routes of travel and/or state line odometer readings

IFTA requires a record of the fuel purchased and used by each IFTA licensed vehicle. Evidence of tax-paid fuel purchases is required to obtain credit on the quarterly report. Evidence includes a receipt or invoice, credit card receipt, or automated vendor-generated invoice showing the tax that was paid for the fuel purchase.

Tax-paid fuel purchase evidence must contain:

1.Date of purchase

2.Seller's name and address

3.Number of gallons/liters purchased

4.

Beginning and ending odometer or hub odometer

4.

Fuel type

 

 

readings.

5.

Price per gallon or liter or total amount of sale

 

 

 

5.

Total trip miles

6.

Unit numbers

 

 

 

 

 

6.

Mileage by state/province (determined by state line

7.

Purchaser’s name (in case of a lessor/lessee agree-

 

odometer reading or route of travel)

 

 

ment, receipts will be accepted in either name, pro-

 

 

 

 

7.

Unit number or vehicle identification number (VIN)

 

vided a legal connection can be made to reporting

8.

Vehicle fleet number

 

party)

 

 

 

 

9.

Registrant’s name

Note: Altered receipts will not be accepted.

 

 

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

 

 

 

 

PS2237-01 Rev. 5/2007

 

 

DRIVER AND VEHICLE SERVICES DIVISION

Fuel Records (cont.)

A bulk metered record can be used when tax-paid fuel is withdrawn from bulk storage. The bulk metered record must show:

1.Date of withdrawal

2.Number of gallons

3.Fuel type

4. Unit number, license plate number, or VIN

5. Purchase and inventory records

to substantiate that tax was paid Helpful Hint! on all bulk fuel purchases

 

Print Trip Report

 

form on an 8 ½ x 11”

 

envelope and keep

Recaps

receipts inside.

 

Mileage & Fuel Summaries

IRP and IFTA require carriers to maintain a monthly summary of miles traveled and fuel purchased for each vehicle (see sample form).

Monthly totals for the following items are required for all vehicles in the fleet:

Miles driven by state/province.

Fuel purchased by state/province.

Total mileage driven.

Total fuel purchased.

Record Retention

IFTA Retention Requirement – Records used to support the information reported on the fuel tax returns (miles and fuel purchases) must be retained for four years from the filing date of the return.

IRP Retention Requirement – Mileage records used to support the information reported on the annual renewal must be retained for three years after the close of the registration year.

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

RIVER AND VEHICLE SERVICES DIVISION

DRIVER AND VEHICLE SERVICES DIVISION

Prorate Office

445 Minnesota Street

Saint Paul, Minnesota 55101-5188

Phone: 651/205-4141

Fax: 651.215.0027

TTY: 651/282-6555

Web: www.dps.state.mn.us/

Audit

Carriers are audited periodically to ensure that accept- able records are maintained. If the carrier’s records are not located or made available in Minnesota, the auditor’s travel expenses and per diem will be billed to the license holder upon completion of the audit.

Failure to provide adequate mileage and fuel documen- tation may result in the following audit assessments:

IRP Registration Tax Penalty – An additional tax liabil- ity of 20% of the Minnesota base registration tax.

Fuel Tax Penalty – Use of four miles per gallon as the standard used to determine fuel tax liability for all au- dited quarters.

In addition, failure to maintain fuel receipts or invoices will result in denial of a fuel tax credit.

IFTA Filing Dates

IFTA tax reports are filed on a quarterly basis. Reports are due the last day of the month following the end of the quarter. If the last day of the month falls on a Saturday, Sunday, or legal holiday, the next business day is considered the filing due date.

All returns must be US postmarked by the deadline (bold date) to be considered timely:

April 30 – 1st Quarter (January-March) July 31 – 2nd Quarter (April-June)

October 31 – 3rd Quarter (July-September) January 31 – 4th Quarter (October-December)

Note: Filing is required even when no miles were traveled during the quarter.

Penalties for failure to file a report, for filing a late report, or for underpayment of fuel taxes are:

$50.00 or 10% of the net tax liability, whichever is greater; and

Interest at a rate of 1% per month.

Account Closing Process

If it is necessary to close the Prorate account, you must:

1.Complete Minnesota IRP Renewal/Supplement Ap- plication and/or IFTA quarterly report;

2.Ensure that there are no outstanding tax liabilities;

3.Turn in plates, stickers, cab cards, and/or IFTA li- cense and unused IFTA decals; and

4.Retain operational records for four years after the account is closed.

PS2237-01 Rev. 5/2007

Page 2

 

 

Trip Report

Registrant/

 

Vehicle (Truck/Tractor)

Carrier Name

 

ID Number

Trip Origin

 

Fleet Number

 

 

 

 

 

Complete this report monthly or more frequently

Date State/ Province

Odometer

Daily beginning/state line

Highways Traveled

Destination/ Stops

Miles

Fuel Purchased (gallons)

*Ending Odometer

Reading

Total Odometer

Miles

Total Miles by State/Province

Total Trip Miles

Driver’s Name

MN: ________ _____ : __________ _____ : ___________ _____ : __________ _____ : __________

*Ending odometer reading should be the same as the next trip’s beginning odometer reading.

PS2237-01 Rev. 5/2007

Sample Trip Report

Page 3

 

Monthly Mileage and Fuel Summary

Registrant/

 

Vehicle (Truck/Tractor)

Carrier Name

 

ID Number

 

 

 

 

Quarter/Year

 

Fleet Number

 

 

 

 

Include only IRP and/or IFTA qualified vehicles (over 26,000 pounds GVW or three or more axles).

Include all fuel pumped into the power unit.

State/ Province

Month

 

Month

 

Month

 

 

 

 

 

 

Miles

Fuel

Miles

Fuel

Miles

Traveled

Purchased

Traveled

Purchased

Traveled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Quarter Total

 

 

 

Fuel

Miles

Fuel

Purchased

Traveled

Purchased

Monthly Totals

PS2237-01 Rev. 5/2007

Sample Monthly Mileage and Fuel Summary

Page 4

IRP Minnesota Presence Affidavit

IMPORTANT: READ BEFORE YOU COMPLETE THIS FORM

Why are you being asked to share this information and how will it be used?

An International Registration Plan (IRP) registrant who declares Minnesota as the base jurisdiction must provide evidence of a Minnesota presence (an established place of business or residence).

The Department of Public Safety (DPS) will use the information to identify you as a registrant or authorized agent of the registrant, to create or identify your Minnesota prorate account, to determine your eligibility for Minnesota prorate registration, to access your record for any future service transactions and/or inquiries, and to comply with state and federal laws.

State law authorizes collection of this information.

The International Registration Plan (IRP) entered into under the authority of Minnesota Statutes, section 168.187, subdivision 7, requires this information. Minnesota Rules, part 7410.0400, requires proof of identity for vehicle registration and title transactions.

Consequences of supplying or refusing to supply requested information.

If you supply the requested information, the DPS will be able to determine whether to issue you Minnesota title and prorate registration.

If you don’t provide the information requested, the DPS cannot issue you title or prorate registration and your eligibility for any current registration may be affected.

How is the requested information shared with other agencies?

The DPS releases this information to local, state, and federal government agencies only as authorized or required by state and federal law. This means that the information may be shared with the Federal Motor Carrier Safety Administration (FMCSA) and IRP member states. In addition, your personal information may also be disclosed as authorized in the United States Code, title 18, section 2721.

Permissible Uses of Motor Vehicle Data as provided in United States Code, title 18, section 2721

1.For use by any government agency, including court or law enforcement agency, in carrying out its functions, or any private person or entity acting on behalf of a federal, state or local agency in carrying out its functions.

2.For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

3.For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only:

(A)to verify the accuracy of personal information submitted by the individual to the business or its agencies, employees, or contractors; and

(B)if such information as so submitted is not correct or is no longer correct, to obtain correct information, but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against the individual.

4.For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state or local court or agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of a federal, state or local court.

5.For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, re- disclosed, or used to contact individuals.

6.For use by any insurer or insurance support organization, or by self-insured entity, or its agents, employees, or contractors, in connection with claims investigation activities, antifraud activities, rating or underwriting.

7.For use in providing notice to the owners of towed or impounded vehicles.

8.For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

9.For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver’s license that is required under the Commercial Motor Vehicle Safety Act of 1986 (49 U.S.C. App. 2710 et seq.).

10.For use in connection with the operation of private toll transportation facilities.

11.For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the person to whom such personal information pertains.

12.For bulk distribution for surveys, marketing, or solicitations if the state has obtained the express consent of the person to whom such personal information pertains.

13.For use by any requester, if the requester demonstrates it has obtained written consent of the individual to whom the information pertains.

14.For any other use specifically authorized under the law of the state that holds the record, if such use is related to the operation of a motor vehicle or public safety.

Minnesota Department of Public Safety Driver and Vehicle Services Division

445 Minnesota Street Saint Paul, Minnesota 55101-5188

Office: (651) 205-4141 or TTY: (651) 282-6555

PS2230-03 Rev. 11/2008

IRP Minnesota Presence Affidavit

_______________________________________________

____________________________________________

(Print Registrant/Company Name)

(Print Authorized Signer’s Name and Title)

I, the undersigned, declare Minnesota as the base jurisdiction of the International Registration Plan (IRP) registrant named above. Minnesota presence is based on item 1 or item 2 (mark only one box).

1. The registrant has an established place of business in Minnesota that meets all of the following conditions:

___

Physical structure located within Minnesota (building or office) owned or leased by the registrant

___

Street address (not a post office box) ___________________________________________________________

___

Open for business. List business hours:_________________________________________________________

___

Vehicles will accrue miles in Minnesota

 

* And located within the physical structure:

___

Permanent employee(s) of the registrant conducting the registrant's trucking-related business

___

The operational records of the fleet (or records will be made available to the state when requested)

 

* Shall be presented with this affidavit:

___

Articles of Business Incorporation (including certificate) issued by authorized state agency

___

Minnesota Secretary of State Certificate of Authority (required for foreign state/province corporations)

___

Ownership documents or Lease agreement records associated with the physical structure

___

List of permanent Minnesota employees that are currently in employment by the registrant

2. The registrant is a Minnesota resident and does not have an established place of business. Shall be presented with this affidavit (three items from Column A or B required):

___ Vehicles will accrue miles in Minnesota

___ The operational records of the fleet (or records will be made available to the state when requested)

All documents shall be current and list registrant name and Minnesota address

 

Column A:

Individual

___

Minnesota driver’s license card

___

Federal income tax return (filed)

___

Minnesota personal income tax records (paid)

___

Minnesota property/estate tax records (paid)

___

Utility billing statement;

 

(i.e. phone, cable, gas, electric, water, etc.)

___

Minnesota motor vehicle title or registration

 

(in registrant’s name)

 

Column B:

Business Entity

___

Minnesota driver’s license card

 

(principle owner must be a MN resident)

___

Minnesota Secretary of State

 

Articles of Incorporation

___

Federal income tax return (filed)

___

Minnesota personal income tax records (paid)

___

Minnesota property/estate tax records (paid)

___

Utility billing statement;

 

(i.e. phone, cable, gas, electric, water, etc.)

___ Minnesota motor vehicle title or registration (in registrant’s name)

I hereby affirm that I received all privacy warnings required by state and federal law. The information I provided is true and correct. The registrant is familiar with the record keeping and mileage recording requirements imposed by the International Registration Plan (IRP). The operational records and any other pertinent information required by the base jurisdiction (Minnesota) are available upon request. The registrant is in compliance with the laws requiring insurance while operating motor vehicles upon public roads and will maintain the required insurance coverage. The Base Jurisdiction may accept information or use other evidential factors it deems pertinent to verify that an Applicant or Registrant has an Established Place of Business or residency within the Base Jurisdiction.

Registrant/Authorized Signature: ____________________________________________ Date: ____________________

(Power of Attorney form required for authorized third party/service bureau)

Minnesota driver’s license number _____________________________________________________________________

(Required if one has been issued to the registrant/authorized signer)

Minnesota Department of Public Safety Driver and Vehicle Services Division

445 Minnesota Street Saint Paul, Minnesota 55101-5188

Office: (651) 205-4141 or TTY: (651) 282-6555

PS2230-03 Rev. 9/2008

New Prorate Applicant Questionnaire

Full Name (print):

Office Use Only

Prorate Acct. #:

Date:

Business Name (if any):

Contact Phone:

Why are you being asked to share this information and how will it be used?

The Department of Public Safety (DPS) will use the information to determine your eligibility for Minnesota prorate registration, to access your record for any future service transactions and/or inquiries, and to comply with state and federal laws.

State law authorizes collection of this information.

The International Registration Plan (IRP) entered into under the authority of Minnesota Statutes, section 168.187, subdivision 7, requires this information.

Consequences of supplying or refusing to supply requested information.

If you supply the requested information, the DPS will be able to determine whether to issue you Minnesota title and prorate registration. If you don’t provide the information requested, the DPS cannot issue you title or prorate registration and your eligibility for any current registration may be affected.

How is the requested information shared with other agencies?

The DPS releases this information to local, state, and federal government agencies only as authorized or required by state and federal law. This means that the information may be shared with the Federal Motor Carrier Safety Administration (FMCSA) and IRP member states. In addition, your personal information may also be disclosed as authorized in the United States Code, title 18, section 2721.

1.What do you haul (check all that apply)?

General Freight

Mobil Homes

Household Goods

Machinery, Large

Metal

Beverages

Coal, Coke

Fresh Produce

Motor Vehicles

Intermodal Containers

Drive Away, Tow

Passengers

Logs, Poles, Beams

Oil Field Equipment

Building Materials

Livestock

2. What type of operation is it?

 

Authorized for hire

Private; passengers

Exempt for hire

(non-buses)

 

Private; property

Rental

 

Private; carrier

Farm

 

Private; passengers

Migrant

 

(buses)

Bus

Grain, Feed, Hay

Meat

Garbage, Refuse, Trash

US Postal Mail

Chemicals

Commodities: Dry, Bulk

Refrigerated Foods

Paper Products

Construction Moving Company US mail

Federal Government State Government Local Government

Utility

Farm Supplies

Construction

Water Well

Other: __________

_______________

_______________

Indian Tribe

Other: __________

_______________

_______________

_______________

3.How many vehicles are you prorating (include those you own that are leased to another company)? ______________

4.Where are these vehicles currently registered?

Minnesota

Other jurisdiction: ___________________________________________________________

5.How are these vehicles currently registered?

Base plate (list plate number(s)): _______________________________________________________________

__________________________________________________________________________________________

IRP plate (list plate number(s)): ________________________________________________________________

__________________________________________________________________________________________

New purchase from (seller’s name): _____________________________________________________________

Seller’s relationship to applicant (if any): _________________________________________________________

Other (explain in detail): ______________________________________________________________________

PS2231-01 Rev. 5/2007

Minnesota Department of Public Safety Driver and Vehicle Services Division

445 Minnesota Street Saint Paul, Minnesota 55101-5188

Office: (651) 205-4141 or TTY: (651) 282-6555

New Prorate Applicant Questionnaire

Page 2

6.

Do you have bulk fuel tanks?

 

 

 

No

Yes, used for prorated vehicles only

Yes, used for prorated and non-prorated vehicles

7.

If you have bulk fuel tanks, how is the fuel monitored and allocated (check all that apply)?

 

Individual fuel tickets

Log sheets

Meter readings

8.

Have you ever had IRP registration in Minnesota or any other jurisdiction?

 

No

Yes (jurisdiction and registered name or account #): ______________________________________

9.

In the last three years, have you been associated with a company or individual with a prorated account?

 

No

Yes (jurisdiction and registered name or account #): ______________________________________

 

 

________________________________________________________________________________

10.

Have you ever been denied registration?

 

 

No

Yes (explain in detail): ______________________________________________________________

11.

Has your registration ever been suspended and/or revoked?

 

No

Yes (explain in detail): ______________________________________________________________

12.

Is(are) your vehicle(s) presently leased to an individual or company?

 

No

Yes (lessee name, address, and phone number): _________________________________________

13.Under what authority (USDOT number displayed on vehicle) are you operating? _____________________________

Jurisdiction of issuance: _________________________________________________________________________

Authority holder (self or name, address, phone): ______________________________________________________

14.Have you ever been audited by Minnesota or another IRP member jurisdiction?

 

No

Yes (approximate date, jurisdiction): ___________________________________________________

15.

Has(have) your vehicle(s) accrued actual mileage (past mileage history)?

 

No

Yes (explain) _____________________________________________________________________

16.

Have you been instructed on the importance of maintaining vehicle distance records?

 

No

Yes

17.

Address where records will be maintained for audit purposes: ____________________________________________

 

_____________________________________________________________________________________________

18.Who will be responsible for filing IRP returns? ________________________________________________________

19.Who will be responsible for filing IFTA returns? ________________________________________________________

20.Additional information/questions: ___________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I hereby affirm that the information provided is true and correct. The registrant is familiar with the record keeping and mileage recording requirements imposed by the International Registration Plan (IRP) and International Fuel Tax Agreement (IFTA). The operational records and any other pertinent information required by the base jurisdiction (Minnesota) are available upon request. The registrant is in compliance with the laws requiring insurance while operating motor vehicles upon public roads and will maintain the required insurance coverage.

_____________________________________________________________

______________________

Signature, Title

Date

PS2231-01 Rev. 5/2007

Minnesota Department of Public Safety Driver and Vehicle Services Division

445 Minnesota Street Saint Paul, Minnesota 55101-5188

Office: (651) 205-4141 or TTY: (651) 282-6555

Estimated Mileage Worksheet

(Submit with Minnesota IRP Renewal/Supplement Application)

Why are you being asked to share this information and how will it be used?

An International Registration Plan (IRP) registrant must justify estimated mileage and show how the estimate was determined. The Department of Public Safety (DPS) will use the information to identify your Minnesota prorate account, to determine your eligibility for Minnesota prorate registration, to access your record for any future service transactions and/or inquiries, and to comply with state and federal laws.

Use the worksheet on the other side of this form to calculate estimated mileage for the registration year (12 months). If your estimates are not reasonable, the base jurisdiction (Minnesota) is required by the IRP agreement to make adjustments as necessary. If mileage is estimated and the fleet is found to have accrued actual mileage in the jurisdiction during the report year, applicable fees will be assessed, including penalty and interest.

State law authorizes collection of this information

The International Registration Plan (IRP) entered into under the authority of Minnesota Statutes, section 168.187, subdivision 7, requires this information.

Consequences of supplying or refusing to supply requested information

If you supply the requested information, the DPS will be able to determine whether to issue you Minnesota title and prorate registration. If you don’t provide the information requested, the DPS cannot issue you title or prorate

registration and your eligibility for any current registration may be affected.

How is the requested information shared with other agencies?

The DPS releases this information to local, state, and federal government agencies only as authorized or required by state and federal law. This means that the information may be shared with the Federal Motor Carrier Safety Administration (FMCSA) and IRP member states. In addition, your personal information may be disclosed as authorized in the United States Code, title 18, section 2721.

Instructions if route of travel is not known: Enter the miles, from column 2, times the number of vehicles registered in the fleet in column 7. When finished, transfer the Total Estimate to Section 3 of the IRP Renewal/Supplement Application.

Column 1: Circle the two letter designation (e.g., MN ) of each jurisdiction for which mileage is estimated.

At the bottom of the column, enter the total number of jurisdictions estimated.

Column 2: Estimated miles for the jurisdiction If the route of travel is not known, enter the miles from column 2 times the numbers of vehicles registered in the fleet in column 7.

Column 7: Column 2 times number of vehicles registered in the fleet in column 7.

Instructions if route of travel is known: Complete columns 3 through 7. When finished, transfer the Total Estimate to Section 3 of the IRP Renewal/Supplement Application.

Column 3: Entry location for the jurisdiction (used when route of travel is known)

Column 4: Exit or final destination within that jurisdiction (used when route of travel is known)

Column 5: Round trip distance between locations in column 3 and column 4

Column 6: Number of Trips per fleet for this route

Column 7: Multiply column 5 by column 6 and enter the result

At the bottom of the column, enter the total estimated mileage

Minnesota Department of Public Safety Driver and Vehicle Services Division

445 Minnesota Street Saint Paul, Minnesota 55101-5188 Office: (651) 205-4141 or TTY: (651) 282-6555

Email: dvs.prorate@state.mn.us

PS2232-03 Rev. 11/11

Estimated Mileage Worksheet—estimates based on 12 months of travel

Account Name:

Account #:

Fleet #:

# of Vehicles:

 

 

 

 

Supplement #:

Registration Year:

1. Jurisdiction:

2. Miles

3.City/Town of Entry Location with

4.City/Town of Exit/Destination with

5.Round Trip

 

6. # Trips

 

7. Total Estimate

Routes of Travel

Routes of Travel

Mileage

 

 

AL

Alabama

834

 

 

 

X

 

=

AL

 

 

 

 

 

 

 

 

 

 

AR

Arkansas

933

 

 

 

X

 

=

AR

 

 

 

 

 

 

 

 

 

 

AZ

Arizona

1,366

 

 

 

X

 

=

AZ

 

 

 

 

 

 

 

 

 

 

CA

California

2,868

 

 

 

X

 

=

CA

 

 

 

 

 

 

 

 

 

 

CO

Colorado

1,064

 

 

 

X

 

=

CO

 

 

 

 

 

 

 

 

 

 

CT

Connecticut

315

 

 

 

X

 

=

CT

 

 

 

 

 

 

 

 

 

 

DC

D.C.

5

 

 

 

X

 

=

DC

 

 

 

 

 

 

 

 

 

 

DE

Delaware

72

 

 

 

X

 

=

DE

FL

Florida

1,615

 

 

 

X

 

=

FL

GA

Georgia

1,776

 

 

 

X

 

=

GA

IA

Iowa

5,625

 

 

 

X

 

=

IA

ID

Idaho

709

 

 

 

X

 

=

ID

IL

Illinois

5,513

 

 

 

X

 

=

IL

IN

Indiana

3,761

 

 

 

X

 

=

IN

KS

Kansas

1,813

 

 

 

X

 

=

KS

 

 

 

 

 

 

 

 

 

 

KY

Kentucky

1,423

 

 

 

X

 

=

KY

LA

Louisiana

545

 

 

 

X

 

=

LA

 

 

 

 

 

 

 

 

 

 

MA

Massachusetts

378

 

 

 

X

 

=

MA

 

 

 

 

 

 

 

 

 

 

MD

Maryland

477

 

 

 

X

 

=

MD

 

 

 

 

 

 

 

 

 

 

ME

Maine

154

 

 

 

X

 

=

ME

MI

Michigan

1,147

 

 

 

X

 

=

MI

MN

Minnesota

21,133

 

 

 

X

 

=

MN

MO

Missouri

2,824

 

 

 

X

 

=

MO

MS

Mississippi

602

 

 

 

X

 

=

MS

MT

Montana

1,953

 

 

 

X

 

=

MT

NC

North Carolina

974

 

 

 

X

 

=

NC

ND

North Dakota

2,580

 

 

 

X

 

=

ND

NE

Nebraska

1,942

 

 

 

X

 

=

NE

NH

New Hampshire

94

 

 

 

X

 

=

NH

NJ

New Jersey

586

 

 

 

X

 

=

NJ

 

 

 

 

 

 

 

 

 

 

NM

New Mexico

1,223

 

 

 

X

 

=

NM

 

 

 

 

 

 

 

 

 

 

NV

Nevada

1,095

 

 

 

X

 

=

NV

 

 

 

 

 

 

 

 

 

 

NY

New York

1,142

 

 

 

X

 

=

NY

 

 

 

 

 

 

 

 

 

 

OH

Ohio

3,784

 

 

 

X

 

=

OH

 

 

 

 

 

 

 

 

 

 

OK

Oklahoma

1,537

 

 

 

X

 

=

OK

 

 

 

 

 

 

 

 

 

 

OR

Oregon

730

 

 

 

X

 

=

OR

PA

Pennsylvania

3,190

 

 

 

X

 

=

PA

RI

Rhode Island

38

 

 

 

X

 

=

RI

SC

South Carolina

623

 

 

 

X

 

=

SC

SD

South. Dakota

2,350

 

 

 

X

 

=

SD

TN

Tennessee

1,630

 

 

 

X

 

=

TN

TX

Texas

3,683

 

 

 

X

 

=

TX

UT

Utah

1,491

 

 

 

X

 

=

UT

VA

Virginia

965

 

 

 

X

 

=

VA

 

 

 

 

 

 

 

 

 

 

VT

Vermont

79

 

 

 

X

 

=

VT

 

 

 

 

 

 

 

 

 

 

WA

Washington

1,084

 

 

 

X

 

=

WA

 

 

 

 

 

 

 

 

 

 

WI

Wisconsin

8,028

 

 

 

X

 

=

WI

 

 

 

 

 

 

 

 

 

 

WV

West Virginia

468

 

 

 

X

 

=

WV

 

 

 

 

 

 

 

 

 

 

WY

Wyoming

1,942

 

 

 

X

 

=

WY

 

 

 

 

 

 

 

 

 

 

AB

Alberta

202

 

 

 

X

 

=

AB

BC

British Columbia

140

 

 

 

X

 

=

BC

MB

Manitoba

581

 

 

 

X

 

=

MB

NB

New Brunswick

39

 

 

 

X

 

=

NB

NL

Newfoundland

16

 

 

 

X

 

=

NL

NS

Nova Scotia

29

 

 

 

X

 

=

NS

ON

Ontario

618

 

 

 

X

 

=

ON

PE

Prince Edward

2

 

 

 

X

 

=

PE

QC

Quebec

192

 

 

 

X

 

=

QC

SK

Saskatchewan

356

 

 

 

X

 

=

SK

 

 

Total Jurisdictions Estimated

 

Total Estimated Mileage

 

 

 

 

 

 

 

 

 

 

 

 

PS2232-03 Rev. 11/11

 

Minnesota Dept. of Public Safety

 

445 Minnesota Street Ste 188

 

St. Paul, MN 55101

 

Phone: (651) 205-4141

 

Fax: (651) 215-0027

Section 1

TDD/TYY: (651) 282-6555

 

 

 

MN International Registration Plan Renewal/Supplement Application

Account Number: _______ Fleet: _____

Account Name:

 

 

Physical Address 1

 

County of Residence

Physical Address 2

 

 

City, State, Zip

 

 

 

Ownership Type:

Company

Section 2

 

Type of Operation:

For Hire

 

DBA:

Mailing Address 1

Mailing Address 2

City, State, Zip

Corporation

Partnership

Sole Owner

Private Carrier

Rent vehicles less than 45 days

Contact Person Name:

 

 

Registration Year:

 

 

 

 

Phone No.

Fax No:

 

Tax ID (FEIN or SSN:)

 

 

 

 

Email Address:

 

 

US DOT #

 

 

 

 

All information collected on a motor vehicle application is required by law and is used to identify the vehicle. Failure to provide required information may result in denial of the requested action. Except for certain uses by federal and state laws, personal information may not be disclosed to anyone without your consent.

Rent vehicles 45 days and over

Section 3

Check the jurisdictions which you want to appear on your cab card for this registration period. Indicate the distance code for each selected jurisdiction as follows:

 

 

A = Actual Miles Reported E = Estimate. For jurisdictions with a distance code of A, report the miles this fleet traveled for the period of________________________________________

 

 

 

 

Jurisdiction

Miles

A/E

 

 

 

 

 

 

 

 

 

 

*

 

 

Alaska

 

 

 

 

 

 

 

Alabama

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Arkansas

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Arizona

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

California

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colorado

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Connecticut

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dist of Columbia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Delaware

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Florida

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Georgia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Iowa

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Idaho

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Illinois

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indiana

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kansas

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kentucky

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4

 

 

 

 

Jurisdiction

Miles

A/E

 

 

 

 

 

 

 

 

 

 

 

 

Louisiana

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Massachusetts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maryland

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Michigan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minnesota

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Missouri

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mississippi

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Montana

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

North Carolina

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

North Dakota

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nebraska

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Hampshire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Jersey

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Mexico

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nevada

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New York

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jurisdiction Miles A/E

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Virginia

Vermont

Washington

Wisconsin

West Virginia

Wyoming

Wyoming Intrastate Authority

 

 

 

 

Jurisdiction

Miles

A/E

 

 

 

 

 

 

 

 

 

 

 

Alberta

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

British Columbia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manitoba

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Brunswick

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Newfoundland/Lab

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nova Scotia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*

 

 

NW Territory

 

 

 

 

 

 

 

 

 

*

 

 

Nunavut

 

 

 

 

 

 

 

 

 

 

 

 

Ontario

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prince Edward Isl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Quebec

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Saskatchewan

 

 

 

 

 

 

 

 

*Yukon

*Mexico

Total Miles

Total Vehicles Renewed

I attest that this vehicle is insured while operated upon the public roads as required by law; proof of insurance will be carried in the vehicle. For any estimated distance reported you are required to use the Estimated Distance Worksheet. I understand that the estimated miles designated reflect intended travel in each state for the current registration year and that mileage cannot be changed during the registration year. I

furthermore affirm that I am familiar with the responsibility imposed upon me by the International Registration Plan (IRP); pursuant to Article II, Section 234 of the IRP you are required to submit, upon request, lease information regarding the owner-operator and the motor carrier.

Applicant Signature: ____________________________________________________ Title: ____________________________________ Date: _____________________________

or

Authorized Agent Signature: ________________________________________________________________________________________ Date: ______________________________

 

 

Minnesota International Registration Plan Renewal/Supplement Application

Section 5

 

Weight Group: #______

Account Number:___________________________

Fleet:____________________________________

 

 

Vehicle Type: ______________________________

Minnesota CGVW: _________________________

This Fleet Is Currently Apportioned With The Jurisdictions Indicated And At The Gross Weights Shown Below:

Jurisdiction

 

Weight

 

 

Jurisdiction

 

Weight

 

 

Jurisdiction

 

 

Weight

 

 

Jurisdiction

 

Weight

 

Jurisdiction

 

Weight

 

Jurisdiction

Weight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AL

 

 

 

 

 

 

 

 

IA

 

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

NM

 

 

 

 

 

 

TN

 

 

 

 

AB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AR

 

 

 

 

 

 

 

 

ID

 

 

 

 

 

 

 

 

MN

 

 

 

 

 

NV

 

 

 

 

 

 

TX

 

 

 

 

BC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AZ

 

 

 

 

 

 

 

 

IL

 

 

 

 

 

 

 

 

MO

 

 

 

 

 

NY

 

 

 

 

 

 

UT

 

 

 

 

MB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CA

 

 

 

 

 

 

 

 

IN

 

 

 

 

 

 

 

 

MS

 

 

 

 

 

OH

 

 

 

 

 

 

VA

 

 

 

 

NB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CO

 

 

 

 

 

 

 

 

KS

 

 

 

 

 

 

 

 

MT

 

 

 

 

 

OK

 

 

 

 

 

 

VT

 

 

 

 

NL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CT

 

 

 

 

 

 

 

 

KY

 

 

 

 

 

 

 

 

NC

 

 

 

 

 

 

OR

 

 

 

 

 

 

WA

 

 

 

 

NS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DC

 

 

 

 

 

 

 

 

LA

 

 

 

 

 

 

 

 

ND

 

 

 

 

 

PA

 

 

 

 

 

 

WI

 

 

 

 

ON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DE

 

 

 

 

 

 

 

 

MA

 

 

 

 

 

 

 

 

NE

 

 

 

 

 

 

RI

 

 

 

 

 

 

WV

 

 

 

 

PE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FL

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

NH

 

 

 

 

 

SC

 

 

 

 

 

 

WY

 

 

 

 

QC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GA

 

 

 

 

 

 

 

 

ME

 

 

 

 

 

 

 

 

NJ

 

 

 

 

 

 

SD

 

 

 

 

 

 

 

 

 

 

 

SK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

** Place a "D" in

the

Action

box if deleting the vehicle.

Place a

"C" in

the

Delete/Change

box

if changing any

vehicle

information.

Please

make

all changes

in red.

 

*1

Verify

the US

DOT number

for the carrier

responsible

for

safety

fitness of

the

vehicle.

This

should be the US DOT number displayed on the cab of the vehicle.

 

*3

Please

indicate

if

the carrier

responsible

for

the

safety

fitness

of

the

vehicle is

expected to

change during this registration year.

 

 

 

 

 

 

 

 

 

*2

Verify

 

the

 

Tax

Identification

Number

 

 

for

the

 

carrier

responsible

for

the

safety

fitness

of

the

vehicle.

 

*5 *4 VerifyIf thecountyunit

keptis

a

whentype

ofnot

TK in withuse travelor

operationin Colorado,(MS please163.051)indicate.

if the

truck

pulls

a

trailer.

 

 

 

 

 

 

 

*6 Please see renewal instructions regarding special use vehicles. Complete if applicable.

VEHICLE EQUIPMENT LIST FOR ACCOUNT _____ - FLEET _____ - WEIGHT GROUP _____

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE EQUIPMENT LIST FOR ACCOUNT _____- FLEET _____ - WEIGHT GROUP _____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Action

Unit#

Year

Make

Plate #

 

Axles

Combined

Combined

Seats

 

Fuel

Unladen Weight

Gross Weight

Purchase Price

Factory Price

Purchase Date

 

 

 

 

 

 

 

MN Axles

QC Axles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.I.N.

 

 

Owner Name

Owner DOB

*1 USDOT

*2 FEIN

 

*3 Yes/No

*4 CO Trailer Y/N

*5 County Kept When Not In Use

*6 Special Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IFTA License and Decals Application

Why are you being asked to share this information and how will it be used?

The Department of Public Safety (DPS) will use the information to identify you as a registrant or authorized agent of the registrant, to create or identify your Minnesota prorate account, to determine your eligibility for a Minnesota IFTA license and decals, to access your record for any future service transactions and/or inquiries, and to comply with state and federal laws.

State law authorizes collection of this information.

The International Fuel Tax Agreement (IFTA) entered into under the authority of Minnesota Statutes, section 168.187, subdivision 7, requires this information.

Consequences of supplying or refusing to supply requested information.

If you supply the requested information, the DPS will be able to determine whether to issue you a Minnesota IFTA license and decals. If you don't provide the information requested, the DPS cannot issue you a Minnesota IFTA license and decals and your eligibility for any current registration may be affected.

How is the requested information shared with other agencies?

The DPS releases this information to local, state, and federal government agencies only as authorized or required by state and federal law. This means that the information may be shared with the Federal Motor Carrier Safety Administration (FMCSA) and IRP member states. In addition, your personal information may also be disclosed as authorized in the United States Code, title 18, section 2721.

Permissible Uses of Motor Vehicle Data as provided in United States Code, title 18, section 2721

1.For use by any government agency, including court or law enforcement agency, in carrying out its functions, or any private person or entity acting on behalf of a federal, state or local agency in carrying out its functions.

2.For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product

alterations, recalls or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

3.For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only: (A) to verify the accuracy of personal information submitted by the individual to the business or its agencies, employees, or

contractors; and

(B)if such information as so submitted is not correct or is no longer correct, to obtain correct information, but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against the individual.

4.For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state or local court or agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of a federal, state or local court.

5.For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, re- disclosed, or used to contact individuals.

6.For use by any insurer or insurance support organization, or by self-insured entity, or its agents, employees, or contractors, in connection with claims investigation activities, antifraud activities, rating or underwriting.

7.For use in providing notice to the owners of towed or impounded vehicles.

8.For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

9.For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under the Commercial Motor Vehicle Safety Act of 1986 (49 U.S.C. App. 2710 et seq.).

10.

For

use

in

connection

with

the

operation

of

private

toll

transportation

facilities.

11.

For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the

 

person to whom such personal information pertains.

 

 

 

 

 

 

 

12.

For bulk distribution for surveys, marketing, or solicitations if the state has obtained the express consent of the person to whom

 

such personal information pertains.

 

 

 

 

 

 

 

 

13.

For use by any requester, if the requester demonstrates it has obtained written consent of the individual to whom the information

 

pertains.

 

 

 

 

 

 

 

 

 

 

 

14.

For any other use specifically authorized under the law of the state that holds the record, if such use is related to the operation of a

 

motor vehicle or public safety.

 

 

 

 

 

 

 

 

 

PS2261-18 REV. 11/2007

Minnesota Department of Public Safety Driver and Vehicle Services Division

 

445 Minnesota Street, Saint Paul, Minnesota 55101-5188 Office: (651) 205-4141 or TTY: (651) 282-6555

IFTA License and Decals Application

New/Renewal License

Exemption

Extra Decals

Prorate Account Name (print):

Physical Address of Business:

Registration Year: _______

Change Account Information

Prorate Acct. #

FEIN: USDOT

#

 

 

Business Mailing Address:

Contact Phone:

Exemptions - If you qualify for one of the following exemptions, check the appropriate box and sign this application.

Company holds a current IFTA license in a jurisdiction other than MN.

Jurisdiction:___________ Acct. #: ______________________

Leased to carrier that reports fuel tax. Carrier name: ____________________________ Jurisdiction: ___________ Acct. #:_______________________

Operating only two-axle vehicles with gross vehicle weight of 26,000 pounds or less.

If you do not qualify for an exemption, complete items 1 through 8 and sign this application.

1. Print names and titles of:

Owner(s)

Partner(s)

Corporate officer(s)

 

(Name)

(Title)

2. Fuel type(s) used (check all that apply):

Diesel

Gasoline

Other _____________

3. Do you maintain bulk storage?

 

NO

YES in MN

YES in: __________

(Name)

(Title)

4.Is your fuel return for a consolidated fleet (vehicles registered in another IRP jurisdiction)?

NO

YES in: ________________________

IFTA Fees and Decals: If requesting extra decals only, do not include annual filing fee and annual license fee. License and decals for the upcoming year must be displayed by February 28.

New/Renewal:

Annual filing fee

$13

 

Annual license fee

$15

 

 

Decals: _______(vehicles) x $2.50

$

 

 

 

 

Grand total

$

 

 

 

Mail this application and check/money order for Grand total to:

Prorate Office

445 Minnesota Street

Saint Paul, Minnesota 55101-5188

Make check/money order payable to Driver & Vehicle Services

I hereby affirm that the information provided is true, correct, and complete. I agree to comply with reporting, payment, record keeping, and license display requirements as specified in the International Fuel Tax Agreement (IFTA). I understand that failure to comply with these provisions is grounds for revocation of the IFTA license in all member jurisdictions and that the base jurisdiction

may withhold any refunds due if I am delinquent on payment of fuel taxes due any member jurisdiction.

_____________________________________________________________ _______________________

(Signature of Taxpayer)

(Title)

(Date)

PS2261-18 REV. 11/2007

Minnesota Department of Public Safety Driver and Vehicle Services Division

 

445 Minnesota Street, Saint Paul, Minnesota 55101-5188 Office: (651) 205-4141 or TTY: (651) 282-6555