Schedule Of State Diversion Corrections {Schedule 11}

State Form 49085 10-03 Supplier Name Schedule 11 Schedule of State Diversion Corrections License Number You may photocopy this blank schedule for future filings. Attach additional sheets as necessary. FEIN Month / Year 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 (4) (1) Carrier Name (2) Carrier FEIN (3) Original Mode Dest. State Revised Dest. State (5) Terminal Code (6) Purchaser Name (7) Purchaser FEIN (8) Date Shipped (10) (9) Net Document Number Gallons (11) Gross Gallons (12) Billed Gallons (13) Diversion Number Total American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Schedule of Diversions Schedule 11 Who Should File This Schedule? Column Instructions: Columns 1 and 2: Enter the name and Federal Identification Number (FEIN) of the company that transports the fuel. This may be you. Column 3: Enter the mode of transport. One of the following codes should be used for each entry J R ST S = = = = Truck P L = Pipeline Rail B = Barge Stock Transfer BA = Book Adjustment Ship (Great Lakes or Ocean Marine Vessel) Column 4: Enter the original destination state as printed on the manifest or bill of lading and the state to which the fuel is being diverted. Column 5: Enter the terminal code number assigned by the IRS. Columns 6, 7, 8, and 9: Enter the purchaser's information, the date shipped, and the document number. Invoice numbers cannot be used in lieu of bill of lading or manifest number. Column 10: Enter the net gallons. Column 11: Enter the gross gallons. Column 12: Enter the billed (invoiced) gallons. This should equal either the net or the gross gallons. Column 13: Enter the diversion number assigned to you by the Department. If you have not obtained a diversion number for each entry, contact the Department for further assistance. All special fuel transported in a motor vehicle with a capacity of more than five thousand four hundred (5,400) gallons must be accompanied by a machine printed shipping paper/bill of lading which includes the 1) name of the seller, 2) name of the purchaser, 3) type of fuel transported, 4) amount of fuel transported, 5) origin state and destination state of the load, 6) whether the fuel is dyed or undyed, and 7) if the destination state is Indiana, the document must state on its face the following: "Indiana special fuel tax billed or collected by supplier or Indiana special fuel tax billed or collected by permissive supplier" or similar wording that has been approved by the Department. Anytime an incorrect shipping paper has been issued or fuel is diverted from the original destination state, a "diversion number" must be obtained from the Department. The diversion number and the corrected information must then be entered on the shipping paper before the fuel can be transported. This schedule should reflect all loads of fuel that have been diverted during the reporting period. The diversion is to be reported by the company diverting the fuel. The "diversion number" must be obtained before the diversion occurs. To obtain diversion numbers, contact the National Fuel Diversion Registry (NFDR) at (888) 367-1600. Failure to comply may result in penalties including fines and/or impoundment, seizure and subsequent sale of your cargo. Before You Begin: Enter your 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 circle. If product type "Other" is specified please name the specific fuel type. Note: All loads of diverted fuel are to be reported on this schedule. This includes tax paid purchases diverted to out-of-state locations and imports into Indiana from another state, tax unpaid. American LegalNet, Inc. www.FormsWorkflow.com