Form Hc-500 - Hazardous Chemical Inventory Fee Return

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Indiana Department of Revenue
HC-500
For Office Use Only
Hazardous Chemical Inventory Fee Return
State Form 46332
Pymt Date
(R/ 01/02)
T
D
R
HE
EPARTMENT OF
EVENUE WILL NOT PROCESS ANY APPLICATION WHICH
F
I
N
S
S
DOES NOT CONTAIN A
EDERAL
DENTIFICATION
UMBER OR
OCIAL
ECURITY
Pymt Amt
N
,
.
UMBER
AND A SIGNATURE OF AN OWNER OR OFFICER OF THE COMPANY
Year Ending
For:
Due:
MAILING ADDRESS
Name
Federal ID Number or Social Security Number
(Enter individual, partnership or corporation name)
Address
City
State
Zip Code
Telephone Number
(including area code)
OWNER INFORMATION
Name
Federal ID Number or Social Security Number
Address
City
State
Zip Code
Telephone Number
(including area code)
HC-500 PAYMENT SUMMARY
Fee Amount
Category
# of Facilities
Per Facility
Balance
A
X
$200.00
=
$
B
X
$100.00
=
$
C
X
$ 50.00
=
$
E
X
$
0.00
=
$
Exempt
1. Total No. of Facilities
Base Tax Due ........... $
2. If paid after the due date, (enter 10% penalty of Line 1) ...................................................... $
3. If paid after the due date, enter interest ............................................................................... $
4. Total Amount Due (add lines 1,2 and 3) ............................................................................. $
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
Environmental Tax Section
100 N. Senate Avenue
Indianapolis, IN 46204-2253

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