Schedule Of Uncollectable Tax From Eligible Purchasers {Schedule 10E}

State Form 49084 (R1/08-04) Schedule 10E Schedule of Uncollectible Tax from Eligible Purchasers Company Name License Number FEIN Month / Year You may photocopy this blank schedule for future filings. Attach additional sheets as necessary. Schedule Type (Check One) 1 2 2E 2K 2X 3 4 Gallons Received, Tax Paid, (Special Fuel Returns Only) Gallons Received from Licensed Distributor or Oil Inspection Distributor, Tax Unpaid Gallons Received for Export (Special Fuel Exporter Only) Gallons of Non-Taxable Fuel Received and Sold or Used for a Taxable Purpose Gallons Received from Distributor on Exchange Gallons Imported Via Truck, Barge, or Rail, Tax Unpaid Gallons Imported into Own Storage Product Code/Type (Check One) For Use with Reporting Special Fuel 142 Kerosene 161 Low Sulphur Diesel #1 - undyed 167 Low Sulphur Diesel #2 - undyed 226 High Sulphur Diesel - dye added 227 Low Sulphur Diesel - dye added 228 Diesel/Fuel Oil Dyed - dye added 231 No. 1 Diesel - dye added 284 Biodiesel - undyed 290 Biodiesel - dye added OTH Other For Use with Reporting Gasoline/Oil Inspection 065 Gasoline 124 Gasohol 125 Aviation Gasoline 130 Jet FuelGasoline 142 Kerosene 150 #1 Fuel Oil - undyed 161 Low Sulphur Diesel #1 - undyed 231 No. 1 Diesel - dye added 241 Ethanol 243 Methanol 282 #1 High Sulphur Diesel - undyed OTH Other Eligible Purchaser (6) Name (7) FEIN (8) Date of Transaction (9) Document Number (10) Billed Gallons (11) Unpaid Indiana Special Fuel Taxes Total $ American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Schedule of Uncollectible Tax from Eligible Purchasers Schedule 10E Who should file this schedule? Only licensed Suppliers and Permissive Suppliers are eligible to file this schedule. A licensed Supplier or Permissive Supplier is entitled to take a deduction on Form SF-900 Line 7, for the amount of Indiana special fuel tax that has become uncollectible from an Eligible Purchaser. Example: Tax due from ABC Oil Company for a sale on February 10, 2002, must be remitted to you by March 15, 2002. If this payment was not received by you before the next return due date, it becomes uncollectible and may be claimed as a deduction on your March return, due April 15, 2002. This deduction is limited to the amount due from the purchaser, plus any tax that accrues from that purchaser for a period of ten (10) days following the date of failure to pay. Before you begin: Enter the identifying information as it is reflected on your Indiana Special Fuel License. Be certain to complete a separate schedule for each fuel product type that you checked. Column instructions: Columns 6 and 7: Enter the name, address, and Federal Identification Number (FEIN) of the Eligible Purchaser from whom the tax is uncollectible. Column 8: Enter the date of the transaction to which the uncollectible tax pertains. Column 9: Enter the document number to which the uncollectible tax pertains. Column 10: Enter the number of gallons billed on which the tax was uncollectible. Column 11: Enter the amount of unpaid Indiana Special Fuel taxes. Carry this total to the SF-900, Line 7. ENTER THE IDENTIFYING INFORMATION AS IT IS REFLECTED ON YOUR INDIANA SPECIAL FUEL LICENSE. American LegalNet, Inc. www.FormsWorkflow.com