Form
Indiana Department of Revenue
ST-103DR
Recap of Prepaid Sales Tax by Distributors
State Form 51068
(R4 / 9-12)
IMPORTANT: This form must be fi led even when no transactions have occured.
1. Taxpayer Identifi cation Number
2. For Tax Period
3. Federal Identifi cation Number
(month/year)
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4. Taxpayer Name
5. Doing Business as Name (DBA)
6. Telephone Number
7. Street Address, City, State Zip Code
8. Gasoline Distributor Status
(Check One)
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Qualifi ed Distributor
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Non-Qualifi ed Distributor
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9. Which sales tax return are you fi ling
ST-103
ST-103MP
None
(Check One)
NOTE: THIS FORM MUST BE PRINTED OR TYPED
Section I:
From Whom Did You Buy Fuel?
10. Name of Supplier
11. Address of Supplier
12. Supplier Federal
13. Total Gallons
14. Prepaid Sales Tax
ID Number
Purchased
Paid to Supplier
Note: You Must Complete BOTH Sides of this Form
15. Grand Totals
Instructions for Section I
1. Provide your Indiana Taxpayer Identifi cation Number (TID).
2. What Tax Period (month/year) Note: This report is due the last day of the month following the reporting period.
3. Enter your Federal Identifi cation Number (FID).
4. Provide the Taxpayer’s legal name.
5. List the Doing Business as Name for your company.
6. Please list your company’s telephone number including area code.
7. Provide your business address.
8. Check your Distributor Status.
9. Check which tax return you are fi ling.
10. List the names of the companies you purchase from.
11. List the address of the companies you purchase from.
12. List your supplier’s Federal Identifi cation Number.
13. List total gallons purchased from each supplier.
14. Provide the amount of prepaid sales tax you paid each supplier.
15. Total the number of gallons purchased and the amount of prepaid sales tax paid for the reporting month.
This report must be fi led MONTHLY. It is due on the last day of the month following the reporting period.
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Please check this box if your business has permanently closed and provide the closed date. ____/____/____