Form Ep-100 - Ethanol Production Credit Application
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2EP-100
FOR DEPARTMENT USE ONLY
Indiana Department of Revenue
State Form
Approval Amt.
#51823
Ethanol Production Credit Application
Rev. 05/04
Approval Date
Indicate period covered for which ethanol was produced: From _______________ to _____________
A. Information Section
Company Name
TID
FID
Indiana Location Address
City
State
Zip Code
B. Producers
1. Total Ethanol produced in Indiana
gallons
Note: Maximum total credit
a. Indiana Credit (Gallons X .125) = .................................................................... $
per taxpayer is $5,000,000.00
C. Credits
Indicate how you anticipate
Sales/Use Tax
Dollar Amount to be Applied: ... $___________________
using this credit:
Adjusted Gross Income Tax .................................................$___________________
Financial Institutions Tax ..................................................... $___________________
Insurance Premium Tax ......................................................... $___________________
Note: The credit can only be applied against sales/use tax liability incurred by the taxpayer.
D. Signature
Under penalties of perjury, I declare that I have examined this document and to the best of my knowledge and belief, it is true, correct,
and complete.
(
)
Printed Name and Title
Telephone Number
Written Signature
Date
Application and a copy of board certification can be faxed to: (317) 233-3064 or Mail form to:
Indiana Dept. of Revenue
Ethanol Production Credit
100 N. Senate Ave., Rm. N203
Indianapolis, IN 46204
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