Indiana Department of Revenue
MF-360X
Amended Consolidated
State Form 49875
(R4 / 7-09)
Gasoline Monthly Tax Return
Due date is the 20th of the following month.
For the month of:_________________ 20_____
Name of License Holder (as indicated on license)
License Number (as indicated on license)
Mailing Address
FEIN/SSN
City or Town
State
Zip Code
Business Telephone Number Contact Name
(
)
Section 1: Filing Types
This is a consolidated return for all license types listed below. Place an “X” in the box to the left of each license type for which you are licensed.
Gasoline
Oil Inspection Distributor
Gasohol Blender
A
B
C
As Reported or Last
Amount of Change
Current
Section 2: Calculation of Gasoline Taxes Due
Determined
Supporting Schedule Must
Amount
Be Attached
1.
Total Receipts (From Section A, Line 8; Column D, on Back of Return)
1.
2.
Total Non-Taxable Disbursements (From Section B, Line 10; Column D, on Back of Return)
2.
3.
Gallons Received, Gasoline Tax Paid (From Section A, Line 1; Column A, on Back of Return)
3.
4.
Billed Taxable Gallons (Line 1 minus Line 2 minus Line 3)
4.
5.
Licensed Gasoline Distributor Deduction (Multiply Line 4 by .016)
5.
6.
Billed Taxable Gallons (Line 4 minus Line 5)
6.
7.
Gasoline Tax Due (Multiply Line 6 by rate on tax chart one (1) in instructions)
7.
+
8.
Adjustments (Schedule E-1 must be attached and is subject to Department approval)
8.
9.
Total Gasoline Tax Due (Line 7 plus or minus Line 8)
9.
Section 3: Calculation of Oil Inspection Fees Due
1.
Total Receipts (From Section A, Line 9; Column D, on Back of Return)
1.
2.
Total Non-Taxable Disbursements (From Section B, Line 11; Column D, on Back of Return)
2.
3.
Gallons Received, Oil Inspection Fee Paid (From Section A, Line 1; Columns D, on Back of Return)
3.
4.
Billed Taxable Gallons (Line 1 minus Line 2 minus Line 3)
4.
5.
Oil Inspection Fees Due (Multiply Line 4 by rate on tax chart two (2) in instructions)
5.
+
6.
Adjustments (Schedule E-1 must be attached and is subject to Department approval)
6.
7.
Total Oil Inspection Fees Due (Line 5 plus or minus Line 6)
7.
Section 4: Total Amount Due Calculation
1.
Total Amount Due (Section 2, Line 9 plus Section 3, Line 7)
1.
(Penalty must be added if report is filed after the due date. 10% of tax due or $5.00,
2.
Penalty
whichever is greater. Five Dollars ($5.00) is due on a late report showing no tax due.)
2.
(Interest must be added if report is filed after the due date. Contact the Department for
3.
Interest
3.
daily interest rates.)
4.
Net Tax Due (Line 1 plus Line 2 plus Line 3)
4.
5.
Payment(s)
5.
For Department Use Only
Check
Check
6.
Balance Due (Line 4 Minus Line 5)
6.
Amount:
Number:
A
B
C
7.
Gallons of Gasoline Sold to Taxable Marinas
7.
Make checks payable to Indiana Department of Revenue and mail to: P.O. Box 510, Indianapolis, Indiana 46206-0510. Include your License Number on check.
Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and, to the best of my knowledge and belief it
is true, correct and complete.
Taxpayer or Authorized Agent
Type or Print Name
Title
Date Signed
Telephone Number
(
)
❑
Please Check Box If Last Filing
Date Business Closed
/
/