KWD-form - Kentucky Weight Distance

Carrier Information

Step 1 - 3

Who is Filing the Form?*

Your USDOT*

Email Address*

Business Phone*

Are You the Owner of the Company?

Yes No

Carrier Tax ID*

Business Type

Sole Proprietor Corporation Partnership Other

Select Required Filing

KYU KIT

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Mailing Address is the Same as Physical Address

Mailing Address

Have you ever had a KIT licence issued to you in another name?

Yes No (If yes, you are required to provide the name and number you operated under.)

Name*

KIT Number*

Was the license cancelled in good standing?*

No Yes

Vehicle Details

Step 2 - 3

VIN*

License Plate*

Issued State*

GVW*

Vehicle Year*

Make*

Model*

Unit*

No.	Year, Make & Model	Licence Plate#	GVW	Action
START ADDING VEHICLE
Total Cost: $

Payment Information

Step 3 - 3

Order Details

Vehicle Total	:
Total Cost	:	$

Billing Address

New Billing Address

Billing Address Same as Physical Address

Billing Address Same as Mailing Address

Street

City

State*

Zipcode

I certify that I am the authorized holder and signer of the credit card referenced above. I certify that all the information above is complete and accurate.

I understand that the information input is correct to my knowledge. Submitting false information could result in penalties and fines. It is a federal crime to submit false information in an attempt to commit fraud.

I hereby authorize the collection of payment to DOT Operating Authority Inc., (DBA) Kentucky Weight Distance Tax, for all charges as indicated above. I acknowledge that charges to my provided payment method may not exceed the total amount listed under the “TOTAL COST” field. I understand that I am responsible for the full amount listed in the “TOTAL COST” field. I understand that this authorization is only in effect during the time period of this transaction. If any additional charges are to need authorization, a new authorization form will have to be completed.

I acknowledge that the total amount of today’s transaction, indicated under the “TOTAL COST” field includes any and all Federal, State, and Local Government fees.

I hereby acknowledge and agree that after the charges are authorized, a DOT Operating Authority Inc., (DBA) Kentucky Weight Distance Tax agent will be assigned within 15 minutes to complete the order. Once the agent has been assigned, the payment cannot be cancelled, and the charges are non-refundable. DOT Operating Authority Inc., (DBA) Kentucky Weight Distance Tax does not accept any responsibility for refusal or reversal of payments, which shall be a matter between you and your credit card issuer.

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Name of person signing

Title

Official Representative

Date signed

03/31/2025

Signature

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Kentucky Weight Distance Tax (WDT) Form a