Form Hc-500 - Hazardous Chemical Inventory Fee Return Form - Indiana Department Of Revenue
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1FOR OFFICE USE ONLY
Indiana Department of Revenue
HC-500
Revised 10/00
Hazardous Chemical Inventory Fee Return
PM DATE
State Form 46332
T
D
R
HE
EPARTMENT OF
EVENUE WILL NOT PROCESS ANY APPLICATION WHICH
PYMT AMT
F
I
N
S
S
DOES NOT CONTAIN A
EDERAL
DENTIFICATION
UMBER OR
OCIAL
ECURITY
N
,
.
UMBER
AND A SIGNATURE OF OWNER OR OFFICER OF THE COMPANY
2001
Year Ending
For: _______________
Due: _______________
December 31, 2000
March 1, 2001
MAILING ADDRESS
Name (Enter individual, partnership or corporation name)
Federal ID Number or Social Security Number
Address
City
State
Zip Code
Telephone Number
(
)
OWNER INFORMATION
Name
Federal ID Number or Social Security Number
Address
City
State
Zip Code
Telephone Number
(
)
HC-500 PAYMENT SUMMARY
Fee Amount
Category
# of Facilities
Per Facility
Balance
A
X
$200.00
=
$
B
X
$100.00
=
$
$
C
X
$ 50.00
=
E
X
$ 0.00
=
Exempt
1. Total No. of Facilities
Base Tax Due
$
2. If paid after the due date, enter 10% penalty of Line 1).......................... $
3. If paid after the due date, enter interest ................................................
$
4. Total Amount Due (Add Lines 1, 2 and 3)..........................................
$
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
Fuel & Environmental Tax Section
100 N. Senate Avenue
Indianapolis, IN 46204-2253
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