Consumers Use Tax Return {ST-115}

Form ST-115 State Form 321 (R4/ 11-02) Indiana Department of Revenue Consumer's Use Tax Return and ending (month/year) Check Type of Return Period beginning (month/year) Name Street Address City or Post Office, County, State, and Zip Code Principal Business Activity ID Type (circle one) Indiana TID # Federal ID # Social Security Number ID Number Quarterly Monthly Tax Computation 1. Total purchases subject to tax (from reverse side).................. 2. Use Tax (6% of Line 1)........................ 3. Penalty (10% of Line 2) & Interest (call the Department*) if paid after due date............... 4. Total amount due (add Lines 2 and 3 )................ For Departmental Use Only $ , , , , , , , . . . . $ , Signature & Title if other than individual return Date I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, correct, and complete return. *Call (317) 233-4015 or by e-mail at: www.in.gov/dor/contact/email.html American LegalNet, Inc. www.FormsWorkflow.com List all purchases of tangible personal property subject to use tax. Name and Address of Seller Description of Property Purchased Date of Purchase Purchase Price of Property $ , , , , , , , , , , , , , (if more space is needed, please attach a schedule) After completing this form, mail with payment to: Indiana Department of Revenue, 100 N. Senate Ave, Indianapolis, IN 46204 TOTAL* $ , *This amount goes on Line 1, on the front of this form. American LegalNet, Inc. www.FormsWorkflow.com . . . . . . .