Form Urt - Indiana Utility Receipts Tax Return

2003 Short Year

Indiana Department of Revenue

(Do Not Write Above)

Indiana Utility Receipts Tax Return

Form URT

Federal Identification Number

State Form

For Initial Fiscal Year

(R/9-02)

Starting from January 1, 2003 to Fiscal Year Ending ____________/_______/2003

Principal Business Activity Code

Name

Street Address

County

Indiana Taxpayer Identification Number

City

State

Zip Code

Telephone Number

K. Check accounting method used:

Cash

Accrual

L. Check box if you have filed for an extension of time to file:

M. Check all boxes that apply to entity:

Initial Return

Final Return

Consolidated Return

In Bankruptcy

Taxable Receipts for Indiana

(List utility receipts received beginning on January 1, 2003 to end date of your short fiscal tax year.)

1. Retail sale of utility services .................................................................................................................................

2. Judgments or settlements as compensation for lost retail sales .........................................................................

3. Sales to a reseller if utility is used in hotels, mobile home parks or marinas ......................................................

4. Sales of water or gas to another for rebottling ...................................................................................................

5. Installation, maintenance, repair, equipment or leasing services provided and charges for removal ...............

6. All other receipts not segregated between retail and non retail transactions ....................................................

7. Total Taxable Receipts (add lines 1 through 6) ...............................................................................................

Deductions

8. Annual taxpayer deduction ($2.74 times number of days from 1-1-2003 to fiscal year end) ...........................

9. Bad debts on utility receipts of an accrual basis taxpayer .................................................................................

10. Depreciation on resource recovery systems prorated for amount attributed to 2003 .......................................

10.

11. Receipts exempt from taxation if included in taxable receipts for the Mobile Telecommunications Sourcing

Act or IC 6-8.1-15. ................................................................................................................................................

11.

12. Amount paid on customarily returned empty reusable containers ......................................................................

12.

13. Receipts from sale of bottled water or gas which was previously taxed .........................................................

13.

14. Total Deductions (add lines 8 through 13) .......................................................................................................

14.

15. Indiana Taxable Utility Receipts (subtract line 14 from line 7) ......................................................................

15.

Tax and Credits

16. Utility Receipts Tax Due for the period: Multiply the amount on line 15 by 1.4% (.014) .............................

16.

17. Estimated payments made for utility receipts tax during short tax year ending in 2003 (list quarterly URT-Q

payments below)

Qtr. 1___________

Qtr. 2___________

Qtr. 3___________

Qtr. 4___________ Enter Total ..

17.

18. Do not use. - For Departmental use.

19. This year's extension payment .............................................................................................................................

19.

20. Total Payments (add lines 17 through 19) ........................................................................................................

20.

21. Net Tax Due (subtract line 20 from line 16, if line 20 is greater than line 16, proceed to line 22 and 26) ........

21.

22. Penalty for underpayment of estimated tax (Attach completed Schedule IT-2220(FY) .....................................

22.

23. Interest: If payment is made after the original due date, add interest (contact the Department for the current

interest rate) ..........................................................................................................................................................

23.

24. Penalty for late payment: If payment is made after the original due date, compute penalty of 10% of line 21 or

$5.00 whichever is greater ..................................................................................................................................

24.

25. Total Amount Owed (Add lines 21 through 24) ...............................................................................................

25.

26. Overpayment (line 20 minus lines 16 and 22) ............................................ 26.

27. Refund (portion of amount on line 26 to be refunded) ................................ 27.

28. Overpayment Credit (carryover to the following year's estimated URT account, line 26 minus line 27) ......

28.

Under penalties of perjury, I declare 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 authorize the Department to discuss my return with my tax preparer.Yes

Signature of Officer

Date

Print or Type Name