Amended Terminal Operators Monthly Return {FT-501X}

State Form 47736 (R4 / 9-13) Form FT-501X Due date is the 20th of the following month. For the month of:_________________, 20_____ Amended Terminal Operator's Monthly Return Indiana Department of Revenue A Terminal Operator's Report Must Be Filed For Each Indiana Location Being Amended Name of License Holder (as indicated on license) Mailing Address City or Town Federal 637 License Number State Zip Code License Number FEIN/SSN Telephone Number Terminal Information Name of Terminal Location Net Gallons as Previously Reported From Schedule Column A Special Fuel (Dyed and Clear Diesel Fuel, Biodiesel, Blended Biodiesel, Compressed Natural Gas, Liquid Natural Gas, Butane, Propane) Column B Gasoline (Gasoline, Gasohol) Column C Other Products (Jet Fuel, Kerosene) Net Gallons as Amended Column A Special Fuel (Dyed and Clear Diesel Fuel, Biodiesel, Blended Biodiesel, Compressed Natural Gas, Liquid Natural Gas, Butane, Propane) Column B Gasoline (Gasoline, Gasohol) Column C Other Products (Jet Fuel, Kerosene) Terminal Code Monthly Transactions for Owned/Leased Terminal Space 1. 2. 3. 4. Beginning Physical Inventory Total Receipts Total Disbursements Stock Gains & Losses (select one) + Ending Physical Inventory (Line 1 plus Line 2 minus Line 3 plus/minus Line 4) Mail to: Indiana Department of Revenue P.O. Box 6080 Indianapolis, IN 46206-6080 501A 501B 5. I do hereby certify under penalty of perjury that, for the terminal location indicated above, the foregoing and attached schedules and reports are a true and correct statement to the best of my knowledge and is a complete and full presentation of all transactions from the best information available. Taxpayer or Authorized Agent Typed or Printed Name Date Signed Title Telephone Number Please Check If Last Filing American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form FT-501X Who Should File This Return? You should file this form if you are an Indiana Licensed Special Fuel Terminal Operator and you need to amend or change a previously filed Terminal Operator's Monthly Tax Return, Form FT-501. How Do I Complete the FT-501X? You should refer to the instructions for your original Terminal Operator's Monthly Tax Return, and related schedules, for the tax period being amended. Enter your company's identifying information on form FT-501X 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 actual license. A separate FT-501X must be filed for each tax period requiring an amendment. Net Gallons as Previously Reported: Complete lines 1 through 5 of Column A, Column B and Column C by entering the amounts as reported on your original tax return, or as previously amended. (If previously amended, lines 1 through 5 will be the amounts reported in column titled "Net Gallons as Amended" of the previously filed amended return.) Net Gallons as Amended: Use this column to report changes in line amounts from those previously reported. Changes in column titled "Net Gallons as Amended" must be documented by attaching the corresponding schedules, as amended. If there is no change to a particular line entry, enter zero. To Obtain Forms To obtain forms, visit our website at www.in.gov/dor/3512.htm. What if I Have Other Questions? For assistance, call (317) 615-2630, or email fetax@dor.in.gov. American LegalNet, Inc. www.FormsWorkFlow.com