Massachusetts Department of Revenue
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International Fuel TaxAgreement |
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Massachusetts LicenseApplication |
2020 |
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Registration period January 1, 2020 through December 31, 2020. |
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edeldetificatiue |
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eatfTsatiue |
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Legalafbusiess |
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Physicaladdssfbusiess |
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iligaddss |
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fficewhefuelcsaavailablefaudit(ifdiffe |
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tfbusiessaddssiligaddss |
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afsetativeaget(icludePweft |
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Yes |
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Tyefbusiess |
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ti dividual Paei the(secify |
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Principal officers. Thissectistbecletedifull |
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Title |
Name |
Social Security number |
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Residential address |
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Registration
egisttitye |
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adateiTg |
eewal |
ditial |
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Fuel type. heckallthataly |
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iesel |
aslie hal Pae(LP diesel L ashl t |
hal ectcity |
ydge |
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Decal order and application fee
1uefTvehicles
2stevehicle
3Ttaldue(ltilyliebylie
Be sure to complete page 2.
Jurisdictions. illithevalexttayjusdictiiwhichyutvel
– aba |
–diaa |
–taa |
P–Pesylvaia |
Y–yg |
– za |
–wa |
–ebska |
–hdeslad |
Canadian provinces: |
–sas |
–sas |
–evada |
–uthalia |
–bea |
–alifia |
–tucky |
–ewashi |
–uthakta |
–tishluia |
–ld |
L–Luisiaa |
–ewy |
T–Teessee |
–itba |
T–ecticut |
–ie |
–ewxic |
TX–Texas |
–ewswick |
–elawa |
–ad |
Y–ewY |
UT–Utah |
L–ewfudlad |
–istctfluia |
–ssachusetts |
–halia |
–et |
–vatia |
L–lda |
–chiga |
–hakta |
–iiia |
–ta |
–eia |
–esta |
–hi |
–ashigt |
P–Pcewaslad |
–dah |
–ssissii |
–klah |
–estiiia |
–uebec |
L–lliis |
–ssu |
–g |
–iscsi |
–skatchewa |
Bulk storage
yuitaibulkstgefYeslistthejusdictiwhethefuelisitaied
Yes 
Prior registration
dicateayTjusdicti(siwhichyuacutlywe |
viuslygisted(te“e”ifyuhaveevebeegisted |
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Important information
asyuTliceseevebeevkediayTjusdicti
Yes 
ListayTjusdictiiwhichyuTliceseiscutlyvked
Declaration
The applicant agrees to comply with reporting, payment, record-keeping requirements to report payments, keep records and license display requirements as specified in the Massachusetts Tax Law and the International Fuel TaxAgreement. The applicant further agrees that Mass- achusetts may withhold any refunds due if the IFTAapplicant is delinquent on payment of fuel taxes due to any IFTAmember jurisdiction. Failure to comply with these provisions shall be grounds for revocation of an IFTAlicense in all member jurisdictions.
Under the penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief it is true, correct and complete.
thzedsigatu(t |
Title |
ate |
Telehe |
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gatufweaeefficefage |
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Instructions
etfeeswithalicatiettacestbeiUfu |
dskecheckayablet |
Commonwealth of Massachusettsilt |
Massachusetts |
Department of Revenue, P.O. Box 7027, Boston, MA02204. |
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