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

This collection of information is mandatory to obtain or retain benefits under 23 U.S.C. 141, and will be used as a simple certification submitted on an annual
basis by the Governor or designated official of each State that the federal Heavy Vehicle Use Tax proof-of-payment provisions are being performed. Public
reporting burden is estimated to average 12 hours per response, including the time for reviewing instructions searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Please note that an agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is
2125-0541. The expiration date for this OMB number is 5/31/2014. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: Michael Howell, E64-433, Information Collection Clearance Officer, Federal Highway
Administration, 1200 New Jersey Avenue, SE, Washington, DC 20590

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 (4-2014)

Save Data Only

Clear Form

Save Data & Form

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

I,

,

of the State of

position

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)