
AMFT-71
Mot or Fuel Ta x Se c t ion
P O Box 1752
Little Rock, AR 7 2 2 0 3
Phone. (501) 682-4815 Fa x (501) 682 -5599
ARKANSAS IFTA APPLICATION
Year
Federal Employee ID Number or Social Security No.
2. Arkansas IRP Account No.
3. U.S. DOT Number
1.
Expiration Date
Applicant’s Legal Name 5. Application Type: 4.
Original Renewal Supplement
Trade/DBA Name (If different than Le gal Name) 7. Applicant’s Arkansas Phone Number 6.
Applicant’s Arkansas Physical Address Street City State Zip 8.
Mailing Address Street or P.O. Box City State Zip 9.
Contact Person’s Name 11. Contact’s Telephone No. 10.
12.
Business Type: Sole Proprietor Partnership Corporation
13.
PRINT OR TYPE PARTNERS OR CORPORATE OFFICERS NAMES(S), TITLE, AND RESIDENCE ADDRESS
14. List Jurisdictions Where You Have Bulk Storage.
15.
NUMBER OF VEHICLES REQUIRING IFTA DECALS NO FEE
CERTIFICATION – The applicant agrees to comply with reporting, payment, record keeping, and display requirements as specified in the
International Fuel Tax Agreement. The applicant authorizes the State of Arkansas to withhold any refund of tax overpayment if delinquent taxes
are due any member IFTA jurisdiction. Failure to comply with these provisions shall be grounds for revocation of the IFTA license in all
member jurisdictions and any falsification subjects him or her to appropriate civic and/or criminal sanction of the base jurisdiction.
APPLICANT AGREES, UNDER PENALTY OF PERJURY, THAT THE INFORMATION GIVEN ON THE IFTA APPLICATION IS,
TO THE BEST OF THEIR KNOWLEDGE, TRUE, ACCURATE, AND COMPLETE.
___________________________________ ___________________________________
Applicant’s Signature Applicant’s Title Date
FOR OFFICE USE ONLY
Decal Registration Numbers: Beginning _________________ Ending _____________ Date Mailed _________
NAME TITLE PHYSICAL RESIDENCE ADDRESS