Form Usu-103 - Utility Services Use Tax - 2006 Page 3
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4Indiana Department of Revenue
Utility Services Use Tax
USU-103 0706
State Form 52709 (R/7-06)
I declare under penalties of perjury that this is a true, correct and complete voucher.
US
X Authorized Signature_____________________________
Date__________________ Telephone # ________________
Name __________________________________________
DBA Name ______________________________________
Address_________________________________________
City_______________________ State_______ Zip_______
Federal Identifi cation Number_________________________________
Social Security Number_____________________________
Taxpayer Identifi cation Number_______________________________
For Tax Period Ending______________________________
Filing Status
Due on or before
MONTHLY
______________________________
A [ ]
Check box if remitting tax as an out-of-state seller of utility services:
B [ ]
Check box if remitting tax as an Indiana consumer of utility services:
1. Total gross sales to Indiana consumers by utility service providers collecting USUT.
1. $ ____________
2. Amount of consumer purchases from utility service providers not collecting USUT.
2. $ ____________
3. Adjustments: Attach proof for any deduction.
3.
$ ____________
4. Total: Enter amount from line 1 or 2 less amount (if any) on line 3.
4.
$ ____________
5. Utility Services Use Tax due: Multiply line 4 by 1.4% (0.014).
5.
$ ____________
6. Interest due: If late, compute 4% annual interest on amount from line 5.
6. $ ____________
7. Late payment penalty: If late, penalty is the greater of $5 or 10% of line 5.
7. $ ____________
8. Overpayment/Underpayment: Carryover from prior period:_____________ Enter amount.
8.
$ ____________
9. Total amount due: Add lines 5 through 8. Remit this amount.
9.
$ ____________
Mail to:
Indiana Department of Revenue
P.O. Box 7228
Indianapolis, IN 46207-7228
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