Form Sf-401x - Amended Transporter'S Monthly Tax Return
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1
2Form
Indiana Department of Revenue
Amended Transporter’s
SF-401X
State Form 47735
Monthly Tax Return
(R4 / 9-13)
For the month of: _________________ 20______
Name of License Holder (as indicated on license)
Mailing Address
City or Town
State
Zip Code
Telephone Number
License Number
Federal Identification Number
Motor Carrier/IFTA Number
Gallons as Previously Reported
Gallons as Amended
From
Column A
Column B
Column C
Column A
Column B
Column C
Schedule
Special Fuel
Gasoline
Other
Special Fuel
Gasoline
Other
(Dyed and
(Gasoline,
Products
(Dyed and
(Gasoline,
Products
Clear
Gasohol)
(Jet Fuel,
Clear
Gasohol)
(Jet Fuel,
Diesel Fuel,
Kerosene)
Diesel Fuel,
Kerosene)
Biodiesel,
Biodiesel,
Blended
Blended
Biodiesel,
Biodiesel,
Compressed
Compressed
Natural Gas,
Natural Gas,
Liquid Natural
Liquid Natural
Gas, Butane,
Gas, Butane,
Propane)
Propane)
1.
Total gallons of fuel loaded
from an Indiana terminal or
bulk plant and delivered to
another state.
1A
2.
Total gallons of fuel loaded
from an out-of-state
terminal or bulk plant and
delivered into Indiana.
2A
3.
Total gallons of fuel loaded
from an Indiana terminal
or bulk plant and delivered
within Indiana.
3A
4.
Total gallons of fuel
transported. (Add lines 1,
2, and 3).
Transporter’s Schedule of Deliveries Schedules 1A, 2A and 3A must be attached to this report.
Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best
of my knowledge and belief it is true, correct, and complete. I further declare that complete and proper records are on file at the address
indicated above for all fuel reported on this return.
Taxpayer or Authorized Agent
Typed or Printed Name
Title
Date Signed
Telephone Number
Important: A return must be filed each month, within 25 days following the last day of the month being reported.
Failure to submit this report could result in a civil penalty of $1,000 for each violation.
Mail Return To: Indiana Department of Revenue
P.O. Box 6080
Indianapolis, IN
46206-6080
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