Form Ft-501x - Amended Terminal Operator'S Monthly Return
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1
2INDIANA DEPARTMENT OF REVENUE
FT-501X
Amended Terminal Operator's
SF# 47736
Monthly Return
(R3 \ 12-08)
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 Being Amended
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
Terminal Code
Name of Terminal
Location
Net Gallons as Previously Reported
Net Gallons As Amended
Column A
Column C
Column A
Column C
Column B
Column B
Special Fuel
Other Prod-
Other Prod-
Special Fuel
From
Gasoline
Gasoline
(Dyed and
ucts
ucts
(Dyed and
Schedule
(Gasoline,
(Gasoline,
Clear
(Jet Fuel,
(Jet Fuel,
Clear Diesel
Gasohol)
Gasohol)
Kerosene)
Diesel Fuel,
Kerosene)
Fuel, Biodiesel
Monthly Transactions For
Biodiesel,
and Blended
Blended
Owned/Leased Terminal Space
Biodiesel)
Biodiesel)
1. Beginning Physical Inventory
2. Total Receipts
501A
501B
3. Total Disbursements
+
-
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
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