Form FHWA 1563 FHWA 1563 Certificate of Enforcement of Heavy Vehicle Use Tax

OMB control number 2125-0541

A Certificate of Enforcement of Heavy Vehicle Use Tax
(23 CFR 669)

I,

, Governor of the State of
, do hereby designate ,

,
position

agency

to issue a certification to the United States Department of Transportation, Federal Highway
Administration, as required by 23 CFR Sec. 669.7.

Signature of Governor

Date of Signature

The above designation should be updated only on an as needed basis as required by 23 CFR 669.

Form FHWA-1563 (9-2003)

Save Data Only

Clear Form

Save Data & Form

One of the following certifications must be submitted annually as required by 23 CFR 669:

I,

,
position

of the State of

agency

, do hereby certif y that evidence of payment of the heavy

vehicle use tax pursuant to section 4481 of the Internal Revenue Code of 1954, as amended, is being
obtained as a condition of registration for vehicles subject to such tax in accordance with 23 U.S.C.
141(c) and applicable IRS rules including Federal apportionment penalties. This certification is for the
period

to

.

Signature of State Official

Date of Signature

I,

, Governor of the State of
, do hereby certify that evidence of payment of the heavy vehicle use tax

pursuant to section 4481 of the Internal Revenue Code of 1954, as amended, is being obtained as a
condition of registration for vehicles subject to such tax in accordance with 23. U.S.C. 141(c) and
applicable IRS rules including Federal apportionment penalties. This certification is for the period
to

.
Signature of Governor

Date of Signature

Form FHWA-1563 (9-2003)