Form Hc-500 - Hazardous Chemical Inventory Fee Return

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For Office Use Only
HC-500
Indiana Department of Revenue
State Form 46332
Hazardous Chemical Inventory Fee Return
Pymt Date:
(R8 / 1/12)
The Department of Revenue will not process any application which
Pymt Amt:
does not contain an Agency Interest (AI) number and
a signature of an owner or officer of the company.
Year Ending: _______________
Due Date: March 1
Owner Information
Name
Federal ID Number or Social Security Number
(Enter individual, partnership or corporation name)
Address
TID
City
State
Zip Code
Telephone Number
The AI number and county associated with the AI must be provided.
Category A
County Name
Category B
County Name
Category C
County Name
AI Number
AI Number
AI Number
Total A:
Total B:
Total C:
Amount Due:
If Late, Penalty:
If Late, Interest:
Amount Paid:
Under penalties of perjury, I have examined this return 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. No copies are allowed.
Mail the Completed Form and Fee To:
Indiana Department of Revenue
For questions related to the HC-500,
Excise Tax Section: Environmental, HC-500
please call (317) 615-2544
P.O. Box 6080
Indianapolis, IN 46206-6080

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