Department of Taxation and Finance

                                 New York State International Fuel                                                                     IFTA-21(9/15)
                                 Tax Agreement (IFTA) Application

  1a This application is for calendar year 1b  Reason for application        New                  Additional license                   For office use only
                                                
                                                                                                                                         $     Number
                                                                             Renewal              Additional decals

  2  Identification Employer identification number Suffix, if any        Social security number                                            Deposit number
    number
                                                                  OR                                                    SS

  3  Type of business    Sole proprietor/individual          Corporation     Partnership        LLC/LLP                    Other:
   4  Legal name                                                                                                                 5 USDOT number

  6  Doing business as (DBA) name (if different from legal name)                                                                 7  Business phone number
                                                                                                                                 (    )
  8  Physical address (number and street)                                9      Mailing address (if different than physical address; number and street or PO box)

     City                                  State        ZIP code                City                                             State     ZIP code

 10 Will you be traveling outside New York State?    11  Are you registered for New York State highway use tax?            12 IRP registration number
       Yes            No                                         Yes     No      If No, see instructions
 13 Have you ever had an IFTA license from a state other than New York?
       Yes            No If Yes, list state(s):
 14 Do you have bulk fuel storage?
       Yes            No If Yes, list in which state(s):

                                                                     Decal order

 15  Number of IFTA vehicles:                      x $8 per set of 2 decals (see instructions) =  ......   15                                            .00

 16  Additional license ($2 fee; mark an Xin the box if needed)          and enter 2 on line 16 .........               16                               .00

 17  Total due (add lines 15 and 16; see below for how to pay)            ............................................  17                               .00
     • Pay the fees (total due)             •  Make check or money order payable in U.S. funds
       with this application                  to Commissioner of Taxation and Finance

  Certification: The applicant agrees to comply with reporting, payment, recordkeeping, and license-display requirements as specified in the New York 
  State Tax Law and the International Fuel Tax Agreement. The applicant further agrees that New York State may withhold any refunds due if the IFTA 
  applicant is delinquent on payment of fuel taxes due to any IFTA member jurisdiction. Failure to comply with these provisions shall be grounds for 
  revocation of any IFTA license in all member jurisdictions.
  I certify with my signature that to the best of my knowledge and belief, the information on this application is true, correct, and complete. I understand 
  that any falsification may subject me to civil and criminal sanctions found in Tax Law section 1815, and Penal Law sections 175.35 and 210.45.
 Type or print name of person signing                                           Title

 Signature of owner, partner, member, officer, or person authorized by attached Power of Attorney Telephone number (with area code)  Date signed

                                                                                                  (    )

For mailing instructions, see Form IFTA-21-I, Instructions for Form IFTA-21.