Form Mf-360 - Consolidated Gasoline Monthly Tax Return - 2003
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1
2INDIANA DEPARTMENT OF REVENUE
Consolidated Gasoline
Monthly Tax Return
MF-360
Due date is the 20th of the following month.
State Form 49276
For the month of:_________________, 20_____
(4-03)
Name of License Holder (as indicated on license)
License Number (as indicated on license)
Mailing Address
FEIN/SSN
City or Town
State
Zip Code
Business Telephone Number Contact Name
Section 1: Filing Types
This is a consolidated return for all license types listed below. Place an “X” in the box to the left of each license type for which you are licensed.
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Gasoline
Oil Inspection Distributor
Gasohol Blender
Section 2: Calculation of Gasoline Taxes Due
1. Total receipts (from Section A, line 7, Column D on back of return)
1
2. Total non-taxable disbursements (from Section B, line 9, Column D on back of return)
2
3. Gallons received, gasoline tax paid (from Section A, line 1, Column A on back of return)
3
4. Net taxable gallons (line 1 minus line 2 minus line 3)
4
5. Licensed gasoline distributor deduction (multiply line 4 by 0.016)
5
6. Net taxable gallons (line 4 minus line 5)
6
7. Gasoline tax due (multiply line 6 by $0.18)
7
+
8. Adjustments ( Schedule E-1 must be attached and is subject to Department approval)
8
9. Total gasoline tax due (line 7 +/- line 8)
9
Section 3: Calculation of Oil Inspection Fees Due
1. Total receipts (from Section A, line 8, Column D on back of return)
1
2. Total non-taxable disbursements (from Section B, line 10, Column D on back of return)
2
3. Gallons received, oil inspection fee paid (from Section A, line 1, Columns D on back of return)
3
4. Net taxable gallons (line 1 minus line 2 minus line 3)
4
5. Oil inspection fees due (multiply line 4 by $0.008)
5
+
6. Adjustments (Schedule E-1 must be attached and is subject to Department approval)
6
7. Total oil inspection fees due (line 5 +/- line 6)
7
Section 4: Calculation of Total Amount Due
1.
Total amount due (Section 2, line 9 plus Section 3, line 7)
1
(Penalty must be added if report is filed after the due date. 10% of tax due or $5.00, whichever is greater. Five
2.
Penalty
2
dollars ($5.00) is due on a late report showing no tax due.)
3.
Interest
3
(Interest must be added if report is filed after the due date. Contact the Department for daily interest rates.)
4.
Net tax due (line 1 plus line 2 plus line 3)
4
5.
Payment(s)
5
For Department Use Only
6.
Balance due (line 4 minus line 5)
Check
Check
6
Amount:
Number:
7.
Gallons of gasoline sold to taxable marinas
7
Make checks payable to Indiana Department of Revenue and mail to:
P.O. Box 510, Indianapolis, Indiana 46206-0510. Include your License
Number on check. 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.
Taxpayer or Authorized Agent
Type or Print Name
Title
Date Signed
Telephone Number
(
)
Please Check Box If Last Filing
Date Business Closed
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