State Form 4949 Form Inirp-B Schedule B - International Registration Plan - Indiana

Form State4949 or the "Form Inirp-b Schedule B - International Registration Plan" is a form issued by the Indiana Department of Revenue.

Download a PDF version of the Form State4949 down below or find it on the Indiana Department of Revenue Forms website.

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Form INIRP-B
Indiana Department of Revenue
State Form 4949
International Registration Plan
R2/ 12-06
Schedule B
1. Registrant Name
7. Fleet Mailing Address
12. IRP Account Number 13. Fleet Number
2. Fleet Street Address
3. County 8. County
9. City
14. US DOT Number
15. IFTA License Number
4. City
5. State 6. ZIP Code 10. State
11. ZIP Code
16. Taxpayer ID Number
17. Fleet Contact Person
Section 2
Jurisdiction Mileage
Method Jurisdiction Mileage Method Jurisdiction Mileage Method
18. Fleet Contact Person Telephone Number
( )
Alberta
A E R Alaska
NR Alabama
A E R
19. Type of Carrier (check all that apply)
Arkansas
A E R Arizona
A E R British Col.
A E R
Private Carrier
Exempt Commodity Carrier
California
A E R Colorado
A E R Connecticut
A E R
“For Hire” Carrier
Household Goods Carrier
(Common Carrier)
Wash. D.C.
A E R Delaware
A E R Florida
A E R
Section 3
Georgia
A E R Iowa
A E R Idaho
A E R
20. Please designate the appropriate year for the Mile-
Illinois
A E R Kansas
A E R Kentucky
A E R
age Reporting Period of July 1, __________ through
Louisiana
A E R Massachusetts
A E R Manitoba
A E R
June 30, __________.
Maryland
A E R Maine
A E R Michigan
A E R
21. Total Indiana Miles
Minnesota
A E R Missouri
A E R Mississippi
A E R
Montana
A E R Mexico
NR New Bruns.
A E R
22. If your Estimated Miles differ than those stated
N. Carolina
A E R N. Dakota
A E R Nebraska
A E R
on Indiana’s Estimated Mileage Chart, please attach
Newfoundland
A E R N. Hampshire
A E R New Jersey
A E R
a Schedule G.
New Mexico
A E R Nova Scotia
A E R Northwest T.
A E R
Under penalty of perjury, I have examined this return
Nevada
A E R New York
A E R Ohio
A E R
and all attachments and to the best of my knowledge
and belief, it is true, complete and correct, and I am
Oklahoma
A E R Ontario
A E R Oregon
A E R
providing proof of financial responsibility prior to af-
fixing my signature hereto.
Pennsylvania
A E R Prince Ed. Is.
A E R Quebec
A E R
Rhode Island
A E R S. Carolina
A E R S. Dakota
A E R
Signature of Owner or Responsible Officer
Title
Date
Saskatchewan
A E R Tennessee
A E R Texas
A E R
Name of your Insurance Company Licensed in Indiana
For Official Use Only
Utah
A E R Virginia
A E R
(not the agency or group)
Actual Miles
Policy Number
Insurance Company Phone Number
Vermont
A E R Washington
A E R
( )
Wisconsin
A E R West Virginia
A E R
NR Miles
Address of Insurance Company
Wyoming
A E R Yukon Terr.
NR
Form INIRP-B
Indiana Department of Revenue
State Form 4949
International Registration Plan
R2/ 12-06
Schedule B
1. Registrant Name
7. Fleet Mailing Address
12. IRP Account Number 13. Fleet Number
2. Fleet Street Address
3. County 8. County
9. City
14. US DOT Number
15. IFTA License Number
4. City
5. State 6. ZIP Code 10. State
11. ZIP Code
16. Taxpayer ID Number
17. Fleet Contact Person
Section 2
Jurisdiction Mileage
Method Jurisdiction Mileage Method Jurisdiction Mileage Method
18. Fleet Contact Person Telephone Number
( )
Alberta
A E R Alaska
NR Alabama
A E R
19. Type of Carrier (check all that apply)
Arkansas
A E R Arizona
A E R British Col.
A E R
Private Carrier
Exempt Commodity Carrier
California
A E R Colorado
A E R Connecticut
A E R
“For Hire” Carrier
Household Goods Carrier
(Common Carrier)
Wash. D.C.
A E R Delaware
A E R Florida
A E R
Section 3
Georgia
A E R Iowa
A E R Idaho
A E R
20. Please designate the appropriate year for the Mile-
Illinois
A E R Kansas
A E R Kentucky
A E R
age Reporting Period of July 1, __________ through
Louisiana
A E R Massachusetts
A E R Manitoba
A E R
June 30, __________.
Maryland
A E R Maine
A E R Michigan
A E R
21. Total Indiana Miles
Minnesota
A E R Missouri
A E R Mississippi
A E R
Montana
A E R Mexico
NR New Bruns.
A E R
22. If your Estimated Miles differ than those stated
N. Carolina
A E R N. Dakota
A E R Nebraska
A E R
on Indiana’s Estimated Mileage Chart, please attach
Newfoundland
A E R N. Hampshire
A E R New Jersey
A E R
a Schedule G.
New Mexico
A E R Nova Scotia
A E R Northwest T.
A E R
Under penalty of perjury, I have examined this return
Nevada
A E R New York
A E R Ohio
A E R
and all attachments and to the best of my knowledge
and belief, it is true, complete and correct, and I am
Oklahoma
A E R Ontario
A E R Oregon
A E R
providing proof of financial responsibility prior to af-
fixing my signature hereto.
Pennsylvania
A E R Prince Ed. Is.
A E R Quebec
A E R
Rhode Island
A E R S. Carolina
A E R S. Dakota
A E R
Signature of Owner or Responsible Officer
Title
Date
Saskatchewan
A E R Tennessee
A E R Texas
A E R
Name of your Insurance Company Licensed in Indiana
For Official Use Only
Utah
A E R Virginia
A E R
(not the agency or group)
Actual Miles
Policy Number
Insurance Company Phone Number
Vermont
A E R Washington
A E R
( )
Wisconsin
A E R West Virginia
A E R
NR Miles
Address of Insurance Company
Wyoming
A E R Yukon Terr.
NR
Schedule B Instructions
SECTION 2
SECTION 1
Line 1: Enter the Registrant Name as it is registered with the Indiana Secretary of State
For each IRP jurisdiction in which you traveled, enter the Total Mileage of the Fleet in the
or the Indiana Department of Revenue. (The IRP Unit will register the Applicant in the
jurisdictions during the appropriate Mileage Reporting Period.
same name as registered with the Indiana Secretary of State or Indiana Department of
Please designate the mileage in the “Method” column by filling in the appropriate A, E, or R.
Revenue.)
Indicate “A” for Actual Miles.
Lines 2 through 6: Enter the Fleet Street Address if different than the Indiana Business
Street Address on the Schedule A.
Indicate “E” for Estimated Miles.
Indicate “R” for Reported Miles.
Lines 7 through 11: Enter the Fleet Mailing Address if different than the Applicant
Mailing Address on the Schedule A. Each Fleet may have an independent mailing address
SECTION 3
where credentials or other correspondence regarding the Fleet will be sent by the IRP
Line 20: Enter the year for the Mileage Reporting Period the miles are being reported.
Unit.
Line 21: Enter the Total Miles for Indiana whether Actual Miles or Estimated Miles.
Line 12: Enter the Indiana IRP Account Number.
Line 22: Please submit a Schedule G with a detailed “Plan of Operation.”
Line 13: Enter the Fleet Number.
The Schedule B must be signed, in INK, by the responsible person. Please include the job title
Line 14: Enter the US DOT Number of the Registrant. All IRP Registrants are required
and date.
to obtain a US DOT Number unique to the Registrant. The US DOT Number should be in
the name in which the Registrant registered with the Indiana Secretary of State or Indiana
Print or type the full name of your insurance company licensed in Indiana (not the agency or
Department of Revenue.
group). Enter your policy number.
Line 15: Enter the International Fuel Tax License Number. The Registrant is responsible
Print or type the address and telephone number of your insurance company.
for providing proof of IFTA responsibility whether through the Registrant having an IFTA
License or through a Lease Agreement.
Effective January 1, 1983, Indiana law requires every Motor Vehicle registered in the State of
Indiana to have proof of Financial Responsibility.
Line 16: Enter the Taxpayer Identification Number of the Applicant. All business entities
must register with the Indiana Department of Revenue and obtain a Taxpayer Identification
Proof of Financial Responsibility includes one of the following:
Number.
1. Motor vehicle’s insurance policy
2. Self insurance (certificate from BMV required)
Line 17: Enter the name of the person who is responsible for conducting the Fleet’s
3. Indiana Motor Carrier Authority Number (IMCA) (PSCI)
business with the IRP Unit. If the Contact Person is not a listed Responsible Officer of
4. $40,000 in securities or cash deposited with the Treasurer of Indiana
the business entity, then a Power of Attorney is required, with the signature of a Responsible
Officer and the Contact Person Designee.
NOTE: If qualified under 2 or 3, place your IMCA number or certificate of self-insurance
number in the policy number area on the front of this form.
Line 18: Enter the telephone number of the Fleet Contact Person.
If qualified under 4, place the word “BOND” in the insurance company name area on the front
Line 19: Enter they Type of Carrier. Please indicate all the Carrier Types that apply to
of this form.
this fleet.
Falsification of this information will subject you to a jail term of up to two (2) years, a
fine of up to $10,000 and suspension of the individual’s driver’s license for a period of up
to one year.
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