Indiana Revenue Form Sf-401x - Amended Transporter'S Monthly Tax Return - Indiana Department Of Revenue
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1
2Indiana Revenue Form
INDIANA DEPARTMENT OF REVENUE
SF-401X
Amended Transporter's
03/02
Monthly Tax Return
SF-47735
For the month of_________________, 20_____
Name of License Holder (As shown on License)
Mailing Address (Street or P.O. Box Number)
State
Zip Code
Telephone Number
City or Town
(
)
License Number.
Federal Identification Number
Motor Carrier / IFTA Number
Net Gallons as Previously Reported
Net Gallons As Amended
Column A
Column B
Column C
Column A
Column B
Column C
Special Fuel
Special Fuel
Gasoline
O t h e r
Gasoline
O t h e r
From
(Dyed and
(Gasoline,
Products
(Dyed and
(Gasoline,
Products
Schedule
Clear Diesel
(Jet Fuel,
C l e a r
Gasohol)
(Jet Fuel,
Gasohol)
Diesel Fuel)
Kerosene)
Fuel)
Kerosene)
1. Total gallons of Special Fuel loaded from
1A
an Indiana terminal or bulk plant and
delivered to another state.
2. Total gallons of Special Fuel loaded from
2A
an out-of-state terminal or bulk plant and
delivered into Indiana.
3. Total gallons of Special Fuel loaded from
an Indiana terminal or bulk plant and
3A
delivered within Indiana.
4. Total gallons of Special 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 file at the
address indicated above for all fuel reported on this return.
Typed or Printed Name
Title
Taxpayer or Authorized Agent
Telephone Number
Date Signed
(
)
IMPORTANT: A return must be filed 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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