Form URT- Q
Utility Receipts - Quarterly Payment
(9-02)
Federal ID Number
Signature of Officer
Title
(
)
Date
Daytime Phone #
Voucher Number
Calendar or FiscalYear Ending
Due Date
Utility Receipts Tax Due for the Quarter Payment Below.
.
.
,
$
,
INDIANA DEPARTMENT OF REVENUE
P.O. BOX 7228
U
INDIANAPOLIS, IN 46207-7228
Do not include check stubs.