Form Hc-500 - Hazardous Chemical Inventory Fee Return
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1
2INDIANA DEPARTMENT OF REVENUE
HAZARDOUS CHEMICAL INVENTORY FEE RETURN
For The Year Ending December 31, 19____
Form HC-500
(Rev. 4/95)
Due MARCH 1, 19____
State Form 46332
Account Number
Title ID# (Issued by IDEM)
OWNER INFORMATION
Name (Enter individual, partnership or corporation name)
Federal ID Number or Social Security Number
Address
City
State
Zip Code
Telephone Number
(
)
Check here if no hazardous chemical was stored from January 1, 19
. through December 31, 19
.
If you no longer store hazardous chemicals and your account should be cancelled, check here.
MAILING ADDRESS (Who should receive this billing?)
Name
Federal ID Number or Social Security Number
Address
County
City
State
Zip Code
Telephone Number
(
)
Fee Amounts
Category
# of Facilities
per Facility
Balance Due
A
________
X
$200.00
=
_________________
For each facility which stores one million (1,000,000) pounds or more of any single chemical (EHS or
Hazardous) at any one during the calendar reporting year.
B
________
X
$100.00
=
_________________
For each facility which store fewer than one million pounds (but equal to or over the TPQ) of any
single chemical (EHS or hazardous) at any one the during the calendar year.
C
________
X
$ 50.00
=
_________________
For each facility which stores chemicals (EHS or Hazardous) equal to or over the TPQ stored in underground
storage tanks only during the calendar reporting year and the facility is in compliance with UST regulations.
E
________
X
$ 0.00
=
EXEMPT
.
For any facility legally exempt from Tier Two filing, including 302-only filers.
$
1. Total No. of Facilities
Base Tax Due
________
$
2. If paid late, enter penalty (10% of Line 1) .........................
$
3. If paid late, enter interest (daily rate .000) ............................
$
4. Total payable to IDOR amount due (Add Lines 1, 2 and 3)
FOR DEPARTMENT USE ONLY
Under penalties of perjury, I declare that I have examined this invoice, including accompanying schedules, and to the best of my
knowledge and belief it is true, correct, and complete.
Signature _________________________________ Date ___________
Daytime Phone_______________
Mail forms to: Indiana Department of Revenue, IGCN 100 North Senate, Indianapolis, IN 46204-2253
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