INDIANA DEPARTMENT OF REVENUE
FT-501
Terminal Operator's
SF# 46291
(R3 /12-08)
Monthly Return
Due date is the 20th of the following month.
For the month of:_________________, 20_____
A Terminal Operator's Report Must Be Filed For Each Indiana Location
Name of License Holder (as indicated on license)
License Number
Mailing Address
FEIN/SSN
Federal 637 License Number
City or Town
State
Zip Code
Business Telephone Number
Terminal Information
Name of Terminal
Terminal Code
Location
Net Gallons
From
Column A
Column B
Column C
Monthly Transactions for
Schedule
Special Fuel
(Gasoline,
Other Products
Owned/Leased Terminal Space
(Dyed and Clear
Gasohol)
(Jet Fuel,
Diesel Fuel,
Kerosene)
Biodiesel, Blended
Biodiesel)
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)
Indiana Department of Revenue
Mail return to:
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 presentation
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