Amended Consolidated Special Fuel Monthly Tax Return {SF-900X}

SF-900X State Form 47737 (R5/01-06) Indiana Department of Revenue Amended Consolidated Special Fuel Monthly Tax Return License Number (As indicated on license) FEIN/SSN State Zip Code Business Telephone Number ( ) For the month of:______________ 20___ This amended report must be filed to correct any previous report with an error or omission. Name of License Holder (As indicated on license) Mailing Address City or Town Contact Name Section 1: Filing Types This is a consolidated return for all license types listed below. Place an "X" in the box to the left of each license type for which you are licensed. Supplier Permissive Supplier Importer Exporter Blender A As Reported or Last Determined Dyed Fuel User B Amount of Change Supporting Sched. Must be attached. C Current Amount Section 2: Computation of Tax 1. 2. 3. 4. 5. 6. 7. 8. 9. Total Receipts (From Section A, Line 5 on back of return) Total Non-Taxable Disbursements (From Section B, Line 11 on back of return) Taxable Gallons Sold or Used (From Section B, Line 3, on back of return) Gallons Received Tax Paid (From Section A, Line 1, on back of return) Billed Taxable Gallons (Line 3 minus Line 4) Tax Due (Multiply Line 5 by $0.16) Amount of Tax Uncollectible from Eligible Purchasers - Complete Schedule 10E Adjusted Tax Due (Line 6 minus Line 7) Collection Allowance (Multiply Line 8 by .016). If return filed or tax paid after due date enter zero (0) 10. Adjustment - Complete Schedule E-1 (Dollar amount only) 11. Total special fuel tax due (Line 8 minus Line 9 plus or minus Line 10) Section 3: 1. 2. + - 3. 4. 5. 6. 7. 8. 9. + - 10. 11. Calculation of Oil Inspection Fees Due (For Periods Beginning after June 30, 2005 Only) 1. 2. 3. 1. Total billed gallons (From Section 2, Line 5) 2. Oil inspection fees due (Multiply Line 1 by $0.01) 3. Adjustments(Schedule E-1 must be attached and is subject to Department approval) 4. Total oil inspection fees due (Line 2 plus or minus Line 3) Section 4: 1. 2 3. 4. 5. 6. Calculation of Total Amount Due + 4. Total amount due (Section 2, Line 11 plus Section 3, Line 4) date. Penalty (Penalty must be added ifa report is filed after the due due.) 10% of tax due or $5.00, whichever is greater. Five dollars ($5.00) is due on late report showing no tax 1. 2. 3. 4. 5. Interest (Interest must be added if report is filed after the due date. Net tax due (Line 1 plus Line 2 plus Line 3) Payment(s) Balance due (Line 4 minus 5) Contact the Department for daily interest rates.) For Department Use Only 6. Check Check Amount: Number: Under the penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. I further declare that complete and proper records are on file at the address indicated above for all fuel reported on this return. Taxpayer or Authorized Agent Typed or Printed Name Date Signed Title Telephone Number ( ) Please Check Box If Last Filing Date Business Closed / / American LegalNet, Inc. www.FormsWorkflow.com Make check payable to Indiana Department of Revenue and mail to: P.O. Box 6080, Indianapolis, Indiana 46206-6080 ( Please include license number on check.) A B As Reported or Last Amount of Change (Supporting Determined Schedule Must Be Attached) C Current Amount Use Whole Gallons Only Section A: Receipts Use Whole From Schedule Gallons Only Use Whole Gallons Only 1. Gallons Received Tax Paid (Carry forward to Section 2, Line 4 on front of return) 2. Gallons Received for Export (To be completed only by licensed exporters) 3. Gallons of Nontaxable Fuel Received and Sold or Used For a Taxable Purpose 4. Gallons Imported Via Truck, Barge, or Rail, Tax Unpaid 5. Total Receipts (Add Lines 1 through 4, carry forward to Section 2, Line 1 on front of return) 1 2E 2K 3 Section B: Disbursements + Use Whole From Schedule Gallons Only Use Whole Gallons Only Use Whole Gallons Only 1. Gallons Delivered Tax Collected and Gallons Blended or Dyed Fuel Used 2. Diversions (Special fuel only) 5 11 - 3. Taxable Gallons Sold or Used (Carry forward to Section 2, Line 3 on front of return) 4. Gallons Delivered Via Rail, Pipeline or Vessel to Licensed Suppliers, Tax Not Collected 5. Gallons Disbursed on Exchange for Other Suppliers or Permissive Suppliers 6. Gallons Exported by License Holder 7. Gallons Sold to Unlicensed Exporters for Export 8. Gallons Sold to Licensed Exporters for Export 9. Gallons of Undyed Fuel Sold to the U.S. Government - Tax Exempt 10. Gallons Sold of Tax Exempt Dyed Fuel 11. Total Non-Taxable Disbursements (Add Lines 4 through 10; carry forward to Section 2, Line 2 on front of return) 6 6X 7 7A 7B 8 10 (Information Only) Reporting of IVP Numbers Given By the Department IVP Number 1. 2. 3. 4. 5. 6. IVP Payment 7. 8. 9. 10. 11. 12. American LegalNet, Inc. www.FormsWorkflow.com IVP Number IVP Payment Instructions for Completing Amended Consolidated Special Fuel Monthly Tax Return SF-900X Refund Due: If Column C, Section 4, line 4 is less than Column C, Section 4, line 5, you are due a refund. Enter the You should file this form if you are an Indiana licensed special amount of your calculated refund in Column C, Section 4, fuel supplier, permissive supplier, exporter, importer, or line 6 in brackets [example]. blender and you need to amend or change a previously filed Consolidated Special Fuel Monthly Tax Return, Form SF- Sign your return, and be sure that it is mailed and postmarked within the statute of limitations period. Your 900. claim for refund will be processed within 90 days of receipt; your refund will be issued, or you will receive an explanation Completing the Form for why the refund was denied or reduced. Who should file this return? You should refer to the instructions for your original Consolidated Special Fuel Monthly Tax Return, and related * Licensed Indiana suppliers and permissive suppliers must make all payments by Electronic Funds Transfer. schedules, for the tax period being amended. What is the Statute of Limitations Enter your company's identifying information on form SFPeriod for Refunds? 900X and all accompanying schedules. Complete all information, leaving nothing blank. It is critical that you use the same license number on this report that is shown on your Generally, you have three (3) years from the date the fuel actual license. A separate SF-900X must be filed for each was purchased and the tax paid to claim a refund. tax period requiring