Form Sw-100 - Solid Waste Management Fee Return
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1
2SW-100
Indiana Department of Revenue
FOR OFFICE USE ONLY
State Form 46830
Solid Waste Management Fee Return
(R3/ 10-11)
PM DATE
T
D
R
PYMT AMT
HE
EPARTMENT OF
EVENUE WILL NOT PROCESS ANY APPLICATION WHICH
F
I
N
S
S
N
,
DOES NOT CONTAIN A
EDERAL
DENTIFICATION
UMBER OR
OCIAL
ECURITY
UMBER
.
AND A SIGNATURE OF OWNER OR OFFICER OF THE COMPANY
For the Month Ending _________________ ________
Year
Due By The 10th of the Following Month
This Form is to be Filed Each Month by All Registered Solid Waste Disposal Facilities in Indiana.
A Separate Form Must be Filed For Each Location.
Taxpayer’s Name:
IDEM Permit Number:
Mailing Address:
City:
State:
Zip Code:
Federal I.D. Number:
Disposal Facility Name:
County of Disposal Facility:
Taxpayer Identifi cation Number:
Facility Address:
City:
State:
Zip Code:
Daytime Phone Number:
In-State
Out-Of-State
1.
Number of Solid Waste Deliveries by vehicles 9,000 lbs. or less ....................................
1
2.
Total tons of solid waste weighed on a qualifi ed scale ....................................................
2
3.
Total tons of COMPACTED solid waste (3.3 cubic yards = 1 ton) ..................................
3
4.
Total tons of UNCOMPACTED solid waste (6 cubic yards = 1 ton) ................................
4
5.
Total. (Add Lines 1, 2, 3, and 4) .....................................................................................
5
6.
Total Fees Due. (Multiply Line 5 by fi fty cents ($.50).......................................................
6
7.
Collection Deduction. (Multiply Line 6 by .01)
Complete ONLY if fi led and paid by due date .............................................................
7
8.
Adjusted Fees Due. (Subtract Line 7 from Line 6) ..........................................................
8
9.
Penalty. Complete if fi led after due date.
Penalty: 10% of total fees due (Line 6) or $5.00, whichever is greater ...................
9
10. Interest. Complete if fi led after due date. See instructions regarding interest ...........
10
+
-
11. Adjustment - Indicate plus or minus (attach explanation)................................................
11
12. Adjusted Fees Due. (Add Lines 8, 9, 10 and +/- Line 11) ..............................................
12
13. NET FEES DUE. (Total both columns on Line 12) .........................................................
13 $
Under penalties of perjury, I have examined this return (including any accompanying schedules and statements) 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. Do Not Send Copies
Mail the Completed Form and Fee To:
Indiana Department of Revenue
Special Tax/Environmental
P.O. Box 6080
Indianapolis, IN 46206-6080
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