Form St-103dr - Recap Of Prepaid Sales Tax By Distributors Page 2

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SECTION II
To Whom Did You Sell Fuel?
16. Customer’s Name
17. Customer’s Address
18. Customer’s Federal
19. Total Gallons Sold
20. Exempt Gallons Sold
21. Prepaid RST Collected
ID Number
All Gallons EXEMPTED and TAXED must be shown
22. Total
Instructions for Section II
16. List your Customer’s Name. (Attach additional sheets if necessary).
17. List your Customer’s Address.
Mail to: Indiana Department of Revenue
18. List your Customer’s Federal ID Number.
Excise Tax
19. List the total gallons of gasoline sold for this month to each customer.
P.O. Box 6114
20. List the total tax exempt gallons sold to each customer.
Indianapolis, IN 46206-6114
21. List the total amount of Prepaid Sales Tax collected for this month from each customer.
(317) 615-2552
22. Total the amounts of all columns and give the total gallonage and amount collected here.
I declare, under penalties of perjury that this is a true, correct and complete report.
______________________________________________
_____________________________________________
__________________________
________________
Printed Name
Authorized Signature
Title
Date

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Parent category: Financial
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