Form Hc-500 - Hazardous Chemical Inventory Fee Return

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HC-500
Indiana Department of Revenue
For Office Use Only
Hazardous Chemical Inventory Fee Return
State Form 46332
Pymt Date:
(R6 / 9-10)
The Department of Revenue will not process any application which
Pymt Amt:
does not contain a Federal Identification Number or Social Security
Number, and a signature of an owner or officer of the company.
Year Ending: _______________
Due Date: _________________
Owner Information
Name
Federal ID Number or Social Security Number
(Enter individual, partnership or corporation name)
Address
Invoice Number
City
State
Zip Code
TID
Telephone Number
Listed below is the facility(s) for which you should be paying, according to the Depart-
ment’s records. Please make any correction needed on this form including adding a
facility or deleting a facility.
Place a check mark by each facility that meets the threshold requirement.
Category A
Category A
Category B
Category B
Category C
Category C
Facility Number
Facility Number
Facility Number
Facility Number
Facility Number
Facility Number
Total A:
Total B:
Total C:
Amount Due:
If Late, Penalty:
If Late, Interest:
Amount Paid:
Under penalties of perjury, I have examined this return (including any accompanying schedules and statements) and to the best of my knowledge and
belief, it is true, correct, and complete.
Signature __________________________________________
Title _________________________________
Date ________________
An Original Signature Must Appear on each Form Filed with the Department of Revenue. Do Not Send Copies.
Mail the Completed Form and Fee To:
Indiana Department of Revenue
For questions related to the HC-500,
Excise Tax Section: Environmental, HC-500
please call (317) 615-2544
P.O. Box 6080
Indianapolis, IN 46206-6080

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