Form Ft-501x - Amended Terminal Operator'S Monthly Return
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1
2Indiana Revenue Form
INDIANA DEPARTMENT OF REVENUE
FT-501X
Amended Terminal Operator's
SF#47736
Monthly Return
Revised 3/02
For the month of:_________________, 20_____
Due the 20th day of the following month
A TERMINAL OPERATOR'S REPORT MUST BE FILED FOR EACH INDIANA LOCATION BEING AMENDED.
Name of License Holder (as indicated on license)
License Number
Mailing Address
FEIN/SSN
Federal 637 License Number
State
Zip Code
Business Telephone Number
City or Town
(
)
Terminal Information
Terminal Code
Name of Terminal
Location
Net Gallons as Previously Reported
Net Gallons As Amended
Column A
Column B
Column C
Column A
Column B
Column C
Special Fuel
Gasoline
O t h e r
Special Fuel
Gasoline
O t h e r
From
(Dyed and
(Dyed and
(Gasoline,
Products
(Gasoline,
Products
Monthly Transactions For
Schedule
C l e a r
Gasohol)
(Jet Fuel,
Clear Diesel
Gasohol)
(Jet Fuel,
Owned/Leased Terminal Space
Diesel Fuel)
Fuel)
Kerosene)
Kerosene)
1. Beginning Physical Inventory
501A
2. Total Receipts
3. Total Disbursements
501B
4. Stock Gains & Losses
+
-
5. Ending Physical Inventory
(Line 1 plus Line 2 minus Line 3
plus/minus Line 4)
Mail Return To: Indiana Department of Revenue, P.O. Box 6080, Indianapolis, IN 46206-6080
I do hereby certify under penalty of perjury that, for the terminal location indicated above, the foregoing and attached
schedules and reports are a true and correct statement to the best of my knowledge and is a complete and full presenta-
tion of all transactions from the best information available.
Taxpayer or Authorized Agent
Typed or Printed Name
Title
Date Signed
Telephone Number
(
)
Please Check Box If Last Filing
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