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IOWA INTERNATIONAL REGISTRATION PLAN VEHICLE SCHEDULE Form 442015 (08-17) Office of Vehicle & Motor Carrier Services P.O. Box 10382 Des Moines, IA 50306-0382 Phone: (515) 237-3268 FAX: (515) 237-3225 Email: [email protected] Web: iowadot.gov/mvd/omcs Registrant Name 1 Unit Number 4 Per Y/N 23 Dealer Name and Address or Previous License # MM/YY of Expiration and State 22 ** Y/N 21 USDOT No. Corresponding Tax ID No. 20 Y/N 19 Transferred License Plate No. and Sticker No. 18 1st Operated Date M/D/Y 17 Purchase Date M/D/Y 16 Lease Date M/D/Y 15 Factory Price 14 Purchase Price 13 Weight Group Number 12 Gross Combined Weight 11 Unladen Weight 10 Jurisdiction Abbrev. & Title Number 9 Complete Vehicle Identification Number 8 Axle Seats or Axles 7 Fuel 6 Make 5 * Type 3 Year 2 Owner Name Doing Business as Second Address Line AL MA LA KY KS IN IL ID IA GA FL DE DC CT CO CA AZ AR NS SK QC PE ON PA NL NB MB BC AB WY WV WI WA VT VA UT TX TN SD SC RI MD OR OK OH NY NV NM NJ NH NE ND NC MT MS MO MN MI ME Physical Address Registrant Only Client ID Registrant's Phone Number Fleet Number FAX Number License Year USDOT Number Tax ID Number Mailing Address Second Address Line Contact Person Name - Regarding Application City,State, ZIP Code Contact Person Email Address Registrant Email Address Contact Person Phone Number City,State, ZIP Code Temporary Evidence of Apportionment (TEAR) requested? If you are a Motor Carrier you will need a US DOT Number to enter into the US DOT Number space. IA DOT OFFICE USE ONLY Supp # Date Reg. Mos. Initials Registration Month: No Yes *If registering a power unit, will you be pulling a trailer? ** Will the control and responsibility for the safety of this vehicle be assigned to a different motor carrier during the registration year? ADDITIONS (See Reverse Side For Instructions and Codes.) No Yes No Yes Straight Deletions or Deletions/Transfer of Credit Unit Number Complete Vehicle Identification Number Deletion Date MM/DD/YY Plate Number Reason Removed Units listed below will be authorized to operate in the jurisdictions and at the weights listed below. List weights in the box for each jurisdiction. 24 Utah TK Type MCO Replacement cab card $3.00 Duplicate Credential Requests Sticker (includes cab card) $3.50 Plate (includes cab card & sticker) $10.00 Fleet-to-Fleet Transfer I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. Title: By: Date:

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IOWA INTERNATIONAL REGISTRATION PLAN VEHICLE SCHEDULE

Form 442015 (08-17)

Office of Vehicle & Motor Carrier Services P.O. Box 10382 Des Moines, IA 50306-0382

Phone: (515) 237-3268 FAX: (515) 237-3225

Email: [email protected] Web: iowadot.gov/mvd/omcs

Registrant Name

1

Unit Number

4 Per Y/N

23

Dealer Name and Address or

Previous License # MM/YY of Expiration

and State

22

** Y/N

21

USDOT No. Corresponding

Tax ID No.

20

Y/N

19

Transferred License Plate No.and Sticker No.

18

1st Operated

Date M/D/Y

17 Purchase

Date M/D/Y

16

Lease Date

M/D/Y

15

Factory Price

14

Purchase

Price

13 Weight Group

Number

12

Gross Combined

Weight

11

Unladen Weight

10

Jurisdiction Abbrev.

& Title Number

9

Complete Vehicle

Identification Number

8

Axle Seats

or Axles

7

Fuel

6

Make

5

* Type

3

Year

2

Owner Name

Doing Business as

Second Address Line

AL MALAKYKSINILIDIAGAFLDEDCCTCOCAAZAR

NS SKQCPEON

PA NLNBMBBCABWYWVWIWAVTVAUTTXTNSDSCRI

MD OROKOHNYNVNMNJNHNENDNCMTMSMOMNMIME

Physical Address

Registrant OnlyClient ID Registrant's Phone Number

Fleet Number

FAX Number

License Year

USDOT Number

Tax ID Number

Mailing Address

Second Address Line

Contact Person Name - Regarding Application

City,State, ZIP Code Contact Person Email Address Registrant Email AddressContact Person Phone Number

City,State, ZIP Code

Temporary Evidence of Apportionment (TEAR) requested?

If you are a Motor Carrier you will need a US DOT Number to enter into the US DOT Number space.

IA DOT OFFICE USE ONLY Supp # Date

Reg. Mos. Initials

Registration Month: No Yes

*If registering a power unit, will you be pulling a trailer? ** Will the control and responsibility for the safety of this vehicle be assigned to a different motor carrier during the registration year?

ADDITIONS

(See Reverse Side For Instructions and Codes.)

No Yes No Yes

Straight Deletions or Deletions/Transfer of Credit

Unit NumberComplete Vehicle

Identification NumberDeletion DateMM/DD/YY Plate Number Reason Removed

Units listed below will be authorized to operate in the jurisdictions and at the weights listed below. List weights in the box for each jurisdiction.

24

Utah TK

Type MCO

Replacement cab card $3.00 Duplicate Credential Requests Sticker (includes cab card) $3.50 Plate (includes cab card & sticker) $10.00 Fleet-to-Fleet Transfer I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct.

Title:

By:

Date:

5S --

Per

man

ent S

emi T

raile

r (5-

year

bill

ing)

App

licat

ion

Inst

ruct

ions

a.

Del

etio

n O

nly

- if y

ou a

ntic

ipat

e ad

ding

a u

nit i

t is

reco

mm

ende

d yo

u ho

ld y

our d

elet

ion

until

that

tim

e to

max

imiz

e yo

ur tr

ansf

er c

redi

t. If

you

do

not a

ntic

ipat

e an

add

, ple

ase

com

plet

e a

vehi

cle

sche

dule

, and

cla

im fo

r ref

und

refo

rm. S

ubm

it th

ese

form

s al

ong

with

the

vehi

cle

plat

e

a

nd re

gist

ratio

n to

the

Iow

a D

epar

tmen

t of T

rans

porta

tion,

Offi

ce o

f Veh

icle

& M

otor

Car

rier S

ervi

ces,

P.O

. Box

103

82, D

es M

oine

s, IA

5

0306

-038

2.

b.

Del

etio

n an

d A

dditi

on (T

rans

fer o

f Cre

dit)

- whe

n a

plat

e is

tran

sfer

red

from

a d

elet

ed u

nit t

o an

add

ed u

nit a

veh

icle

sch

edul

e m

ust b

e co

mpl

eted

. c.

W

eigh

t inc

reas

e - c

ompl

ete

colu

mns

1, 9

, and

12,

indi

cate

the

desi

red

wei

ght i

n th

e ju

risdi

ctio

n bo

x ab

ove.

Com

plet

e th

e bo

xes

on th

e to

p se

ctio

n of

the

sche

dule

. The

reg

istra

nt’s

info

rmat

ion,

incl

udin

g na

me,

DB

A (

if ap

plic

able

), ph

ysic

al a

ddre

ss, c

ity, s

tate

, zip

co

de,

the

com

plet

e m

ailin

g ad

dres

s, (

if di

ffere

nt t

han

the

phys

ical

add

ress

), an

d re

gist

rant

’s p

hone

num

ber

and

emai

l add

ress

. Th

e co

unty

num

ber

is

requ

ired

for “

New

Car

riers

” onl

y. T

he n

ame

and

tele

phon

e nu

mbe

r of t

he c

onta

ct p

erso

n w

ho is

resp

onsi

ble

for f

illin

g ou

t the

app

licat

ion

mus

t be

ente

red.

A

Tax

ID n

umbe

r (TI

N) m

ust b

e gi

ven,

this

is e

ither

a F

eder

al id

entif

icat

ion

num

ber (

FEIN

) or a

Soc

ial S

ecur

ity n

umbe

r (S

SN

), an

FE

IN is

pre

ferr

ed. I

f you

are

a

mot

or c

arrie

r yo

u w

ill n

eed

to e

nter

you

r U

S D

OT

Num

ber

in th

e U

SD

OT

num

ber

spac

e. If

you

are

not

a m

otor

car

rier,

you

shou

ld c

heck

the

regi

stra

nt

only

box

, (yo

u w

ill n

ot n

eed

to e

nter

a U

SD

OT

num

ber)

. Li

st th

e de

sire

d w

eigh

ts in

pou

nds

for e

ach

appo

rtion

ed ju

risdi

ctio

n. V

ehic

les

regi

ster

ed a

t 55,

000

poun

ds o

r mor

e m

ust p

rovi

de c

urre

nt v

erifi

catio

n of

Hea

vy

Veh

icle

Use

Tax

For

m 2

290.

See

IRP

Man

ual f

or a

ccep

tabl

e do

cum

enta

tion.

Doc

umen

tatio

n ca

n ac

com

pany

you

r veh

icle

sch

edul

e or

be

subm

itted

at t

ime

of p

aym

ent.

Col

umn

7

F

uel t

ype:

D

-- D

iese

l G

-- G

as

O

-- O

ther

C

olum

n 8

Num

ber o

f axl

es. V

ehic

les

othe

r tha

n bu

sses

sho

uld

list t

he n

umbe

r of a

xles

in th

e to

p po

rtion

. Pow

er u

nits

nee

d to

list

the

max

imum

num

ber o

f

axl

es fo

r pow

er u

nit a

nd tr

aile

r in

the

low

er p

ortio

n. B

usse

s ne

ed to

list

num

ber o

f sea

ts in

the

botto

m p

ortio

n.

Col

umn

9

V

IN n

umbe

r. A

com

plet

e ve

hicl

e id

entif

icat

ion

num

ber m

ust b

e us

ed.

Col

umn

10

T

itle

num

ber.

Doc

umen

tatio

n m

ust b

e pr

ovid

ed. S

ee IR

P M

anua

l for

acc

epta

ble

docu

men

tatio

n. D

ocum

enta

tion

can

acco

mpa

ny y

our V

ehic

le

S

ched

ule

or b

e su

bmitt

ed a

t tim

e of

pay

men

t. C

olum

n 11

Em

pty

wei

ght.

Col

umn

12

Io

wa

com

bine

d gr

oss

wei

ght f

or w

hich

the

unit

is to

be

regi

ster

ed.

Col

umn

13

W

eigh

t gro

up n

umbe

r for

this

uni

t. C

olum

n 14

Pur

chas

e pr

ice

of u

nit w

hen

acqu

ired.

(Exc

ludi

ng tr

ade-

in a

nd s

ales

tax

but i

nclu

ding

acc

esso

ries

or m

odifi

catio

ns.)

Col

umn

15

T

he m

anuf

actu

rer's

fact

ory

pric

e, e

xclu

ding

trad

e-in

and

sal

es ta

x, in

clud

ing

acce

ssor

ies

or m

odifi

catio

ns a

ttach

ed to

the

vehi

cle.

If th

e fa

ctor

y pr

ice

i

s le

ft bl

ank

the

syst

em w

ill a

utom

atic

ally

fill

this

in u

sing

dat

a fro

m th

e M

anuf

actu

rer's

Sug

gest

ed R

etai

l Pric

e (M

SR

P).

Col

umn

16

L

ease

dat

e - i

f thi

s ve

hicl

e is

bei

ng le

ased

add

mon

th, d

ay a

nd y

ear.

Col

umn

17

P

urch

ase

date

- m

onth

, day

and

yea

r. C

olum

n 18

Mon

th a

nd y

ear t

he v

ehic

le w

as fi

rst p

ut in

ser

vice

, (if

on th

e tit

le o

nly

list).

C

olum

n 19

Lic

ense

pla

te a

nd s

ticke

r num

ber t

rans

ferr

ed fr

om th

e de

lete

d un

it (if

no

trans

fer w

rite

Non

e).

Col

umn

20

'Y

' if u

nit t

rave

ls o

ver 1

0,00

0 m

iles

natio

nally

a y

ear.

'N' i

f uni

t tra

vels

10,

000

mile

s or

less

nat

iona

lly a

yea

r (po

wer

uni

t onl

y).

Col

umn

21

U

SD

OT

num

ber a

ssig

ned

to v

ehic

le a

nd c

orre

spon

ding

Tax

Iden

tific

atio

n N

umbe

r of t

he M

otor

Car

rier R

espo

nsib

le fo

r the

saf

ety

of th

e ve

hicl

e.

See

IRP

Man

ual.

Col

umn

22

W

ill th

e co

ntro

l and

resp

onsi

bilit

y fo

r the

saf

ety

of th

is v

ehic

le b

e as

sign

ed to

a d

iffer

ent m

otor

car

rier d

urin

g th

e re

gist

ratio

n ye

ar?

Col

umn

23

P

revi

ous

licen

se in

form

atio

n, p

late

num

ber,

year

and

sta

te. I

f new

ly p

urch

ased

, giv

e de

aler

nam

e an

d ad

dres

s. F

or a

ny v

ehic

le

w

hich

has

bee

n st

ored

pre

viou

s to

this

lice

nsin

g yo

u m

ust s

ubm

it th

e or

igin

al s

tora

ge s

lip w

ith th

e ve

hicl

e sc

hedu

le.

Col

umn

24

T

op p

ortio

n: U

tah

Spe

cial

Tru

ck In

dica

tor:

If yo

ur p

ower

uni

t is

a: c

emen

t pum

p, w

ell-b

orin

g un

it, O

R c

rane

put

a Y

; if n

one

of th

ese,

leav

e

b

lank

.

B

otto

m p

ortio

n: If

you

r pow

er u

nit i

s ne

w p

ut a

n S

(a c

opy

of th

e M

anuf

actu

rer's

Cer

tific

ate

of O

rigin

(MC

O) m

ust b

e at

tach

ed to

this

form

);

O

ther

wis

e le

ave

blan

k.