Form Ft-501 - Terminal Operator'S Monthly Return - 2000

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Indiana Revenue Form
INDIANA DEPARTMENT OF REVENUE
FT-501
TERMINAL OPERATOR'S
Revised 09/00
MONTHLY RETURN
Due date is the 20th of the following month.
State Form 46291
For the month of:_________________, 20_____
A TERMINAL OPERATOR'S REPORT MUST BE FILED FOR EACH INDIANA LOCATION.
License Number
Name of License Holder (as indicated on license)
Mailing Address
FEIN/SSN
Federal 637 License Number
State
Zip Code
Business Telephone Number
City or Town
(
)
Terminal Information
Name of Terminal
Terminal Code
Location
Net Gallons
From
Column A
Column B
Column C
Schedule
Special Fuel
Gasoline
Other Products
Monthly Transactions
(Dyed and Clear
(Gasohol, Jet Fuel,
(Gasoline Only)
For Owned/Leased Terminal Space
Diesel Fuel)
Kerosene)
1. Beginning Physical Inventory
501A
2. Total Receipts
3. Total Disbursements
501B
4. Stock Gains & Losses
+
-
5. Ending Physical Inventory
(Line 1 plus Line 2 minus Line 3 plus/minus Line 4)
Mail Return To: Indiana Department of Revenue, P.O. Box 6080, Indianapolis, IN 46206-6080
I do hereby certify under penalty of perjury that, for the terminal location indicated above, the foregoing and attached
schedules and reports are a true and correct statement to the best of my knowledge and is a complete and full presenta-
tion of all transactions from the best information available.
Taxpayer or Authorized Agent
Typed or Printed Name
Title
Date Signed
Telephone Number
(
)
Please Check Box If Last Filing

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