Hc-500 State Form 46332 - Hazardous Chemical Inventory Fee Return
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1
2Indiana Department of Revenue
For Office Use Only
Hazardous Chemical Inventory Fee Return
Pymt Date:
The Department of Revenue will not process any application which
does not contain a Federal Identification Number or Social Security
Pymt Amt:
Number, and a signature of an owner or officer of the company.
HC-500
Year Ending:
Due Date:
State Form 46332
(R2/02-06)
Owner Information
Name
Federal ID Number or Social Security Number
(Enter individual, partnership or corporation name)
Address
Invoice Number
City
State
Zip Code
TID
Listed below is the facility(s) for which you should be paying, according to the
Telephone Number
Department’s records. Please make any correction needed on this form including
(
)
adding a facility or deleting a facility.
Place a check mark by each facility that meets the threshold requirement.
Category B
Category A
Category A
Category B
Category C
Category C
Facility Number
Facility Number
Facility Number
Facility Number
Facility Number
Facility Number
Total A:
Total B:
Total C:
Amount Due:
If Late, Penalty:
If Late, Interest:
Amount Paid:
Under penalties of perjury, I have examined this return (including any accompanying schedules and statements) and to the best of my
knowledge and belief, it is true, correct, and complete.
Signature _______________________________________ Title ____________________________________ Date _________________
An Original Signature Must Appear on each Form Filed with the Department of Revenue. Do Not Send Copies.
Mail the Completed Form and Fee To:
Indiana Department of Revenue
Environmental Tax Section HC-500
100 N. Senate Avenue
Indianapolis, IN 46204-2253
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