INDIANA DEPARTMENT OF REVENUE
FT-501
Terminal Operator's
SF# 46291
(R3 /12-08)
Monthly Return
Due date is the 20th of the following month.
For the month of:_________________, 20_____
A Terminal Operator's Report Must Be Filed For Each Indiana Location
License Number
Name of License Holder (as indicated on license)
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
From
Column A
Column B
Column C
Monthly Transactions for
Schedule
Special Fuel
Other Products
(Gasoline,
Owned/Leased Terminal Space
(Dyed and Clear
Gasohol)
(Jet Fuel,
Diesel Fuel,
Kerosene)
Biodiesel, Blended
Biodiesel)
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)
Indiana Department of Revenue
Mail return to:
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 presentation
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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