IFTA License and Decals Application - Minnesota

1 PS2261-21 12/2020 IFTA License and Decals Application Registration YearNew / Renewal License ExemptionExtra Decals change Account InformationCancel Account (Attach License and Decals ) or check box if destroyed, lost or mutilated Account NamePhysical address of BusinessBusiness Mailing AddressAccount NumberFEINUSDOT # Contact Phone Number 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 # Leased to carrier that reports fuel tax. Carrier NameJurisdictionAccount # 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 4 and sign this Application . 1. Print names and titles of: Owner(s) Partner(s) Corporate officer(s)NameTitleNameTitleMINNESOTA DEPARTMENT OF PUBLIC SAFETY DRIVER AND VEHICLE SERVICES 2.

2 Fuel type(s) used (check all that apply): Diesel Gasoline you maintain bulk storage? No Yes in MN Yes in:4. Is your fuel return for a consolidated fleet No Yes in:IFTA Fees and Decals : If requesting extra Decals only, do not include annual filing fee and annual License feeNew/Renewal: Annual filing fee $11 Annual License fee $28 Decals :(vehicles) x $ $Grand Total$Mail this Application and check/money order for Grand total:Driver and Vehicle Servives445 Minnesota Street Saint Paul, Minnesota 55101-5188 Make check/money order payable to Driver & Vehicle Services License and Decals for the upcoming year must be displayed by February 1 of 2 Phone: (651) 205-4141 TTY: (651) 282-6555 Fax: (651) 797-1187 Visit us: Suite 188PS2261-21 12/2020 Tennessen WarningWhat is the purpose of supplying the requested information? The Department of Public Safety ("DPS") collects the information on this form for record keeping purposes as required by the Minnesota Government Data Practices Act, Minn.

3 Stat. (2).Am I required to provide the requested information? You are not legally required to complete this will happen if I do not provide the requested information? You can refuse, however, DPS will consider your Application incomplete, and cannot issue your Minnesota IFTA License and will have access to the requested information? DPS may disclose personal information when it relates to the operation or use of a vehicle or to public safety. The use of personal information relates to public safety if it concerns the physical safety or security of drivers, vehicles, pedestrians or property. The personal information you provided for a Minnesota IFTA License and Decals is classified by 18 2721 and the Minnesota Government Data Practices Act, Minn. Stat. and is subject to the disclosure in accordance with these laws.

4 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 TaxpayerTitleDatePage 2 of 2