Form Sf-401x Amended Transporter'S Monthly Tax Return - Indiana
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1Indiana Department of Revenue
SF-401X
Amended Transporter's
SF# 47735
Monthly Tax Return
(R2/05-07)
For the month of: _________________ 20______
Gallons as Amended
Name of License Holder (As indicated on License)
Mailing Address (Street or P.O. Box Number)
City or Town
State
Zip Code
Telephone Number
License Number
Federal Identifi cation Number
Motor Carrier/IFTA Number
Gallons as Previously Reported
Gallons as Amended
From
Column A
Column B
Column C
Column A
Column B
Column C
Special Fuel
Gasoline
Other Products
Special Fuel
Gasoline
Other Products
Schedule
(Dyed and Clear
(Dyed and Clear
(Gasoline,
(Jet Fuel,
(Gasoline,
(Jet Fuel,
Diesel Fuel,
Diesel Fuel,
Gasohol)
Kerosene)
Gasohol)
Kerosene)
Biodiesel
Biodiesel
and Blended
and Blended
Biodiesel)
Biodiesel)
1.
Total gallons of fuel loaded from
an Indiana terminal or bulk plant
1A
and delivered to another state.
2.
Total gallons of fuel loaded from
an out-of-state terminal or bulk
2A
plant and delivered into Indiana.
3.
Total gallons of fuel loaded from
an Indiana terminal or bulk plant
3A
and delivered within Indiana.
4.
Total gallons of fuel transported.
(Add lines 1, 2, and 3).
Transporter's Schedule of Deliveries
Schedules 1A, 2A and 3A must be attached to this report
Mail Return To:
Indiana Department of Revenue, P.O. Box 6080, Indianapolis, IN 46206-6080
Under 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 fi le at the
adress indicated above for all fuel reported on this return.
Taxpayer or Authorized Agent
Typed or Printed Name
Title
Date Signed
Telephone Number
(
)
Important! A return must be fi led each month, within 25 days following the last day of the month being reported.
Failure to submit this report could result in a civil penalty of $1,000 for each violation.
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