Name:
TAB through the boxes, they will expand as you type
|Name: __________________________ |
|Vehicle Year: ______ Make: ______ Model: ______ |
|VIN: __________________________ Title Number (10 digits): ______________ |
Type of Vehicle (ex., tractor, pickup, van, passenger car, etc.): ______________
Commodity hauled: __________________________
PUCO or Motor Carrier Number (also known as ICC Number): ______________
If you are a Broker or Courier, for whom do you haul? __________________________
__________________________________________________________________________________
Please indicate the percentage of use for each activity that applies to the vehicle. Your total must equal 100%.
a. Hauling goods/products/supplies/equipment for others _____ %
b. Hauling goods/products/supplies/equipment for yourself _____ %
c. Hauling products sold by own business to customers _____ %
d. Hauling construction debris or demolition debris _____ %
Who will own the debris once it is hauled?
________________________________________________________
e. Hauling trash or garbage _____ %
Who will own the trash or garbage once it is hauled?
________________________________________________________
f. Company car (transporting personnel) or repair vehicle _____ %
g. Towing services (vendor’s license required below) _____ %
h. Other _____ %
Please tell us how you use your vehicle on the Description line below:
Description: ______________
Total of lines a. through h. must equal 100% _____ %
I certify that the information I have given on this questionnaire is correct.
Signature: ________________________________________ Date: __________________________
Social Security Number (SSN) or Federal Employer Identification Number (FEIN): ______________
Phone: ______________ Email Address: ______________
Please return the questionnaire and any supporting documentation to us by one of the following methods:
Email: Vehicle.Group@tax.state.oh.us
Fax: 1-206-600-5151
Mail: Ohio Department of Taxation, PO Box 182048, Columbus, OH 43218-2048
TTY/TDD: 1-800-750-0750
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