FORM MCS-3 Indiana Department of Revenue Motor Carrier Services Annual Report Form For the Year Ending December 31, ______ Rev 01/99 State Form 48761 Due April 30th ** NOTICE ** th On or before April 30 of each year, every motor carrier, who operated intrastate motor vehicles for-hire for household goods and/or passengers, over the public highways of the State of Indiana, under a certificate or permit of public convenience and necessity issued by the Department, shall file with the Department an Annual Report for the preceding calendar year. Section A: Motor Carrier Information Legal Name: _______________________________________________________________________________ Doing Business As (D/B/A) Name: _____________________________________________________________ Physical Address: ___________________________________________________________________________ City: __________________________ State: _________________________ Zip Code: __________________ Mailing Address: ___________________________________________________________________________ City: __________________________ State: _________________________ Zip Code: __________________ Contact Person: _________________________________ Phone Number: _____________________________ IMCA# /IN ID#: _________________________ FEIN#: _________________________________ US DOT Number: _________________________ SSN: ___________________________________ Medical Provider #: _______________________ Section B: Kind of Organization (check one) A. ___ Individual B. ____ Partnership C. ___ Corporation D. ___ Other:__________________ Section C: Type of Motor Carrier (check all that apply) 1. _____ Common Carrier 2. _____ Contract Carrier 3. _____ Passenger Carrier 4. _____ Household Goods Carrier Section D: Partnership (complete only if Section B Line B is checked) Partner’s Name Address 1. ______________________________________ 2. ______________________________________ 3. ______________________________________ ____________________________________________ ____________________________________________ ____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Section E: Corporation (complete only if Section B Line C is checked) (A) Directors Address 1. ______________________________________ 2. ______________________________________ 3. ______________________________________ 4. ______________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ (B) Principal General Officers Address 1. ______________________________________ 2. ______________________________________ 3. ______________________________________ 4. ______________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ (C) Principal Stockholders Name 1. _________________________ 2. _________________________ 3. _________________________ 4. _________________________ Address ____________________________________ ____________________________________ ____________________________________ ____________________________________ Number of Shares ______________ ______________ ______________ ______________ Section F: Revenue Equipment (The information below must be given for equipment in service at the end of the year.) Trucks Truck tractors Semitrailers Buses Vans Limousines Other TOTAL Total Vehicles Owned Total Vehicles Leased Total Number of Vehicles Section G: Annual Mileage Transportation of Household Goods Transportation of Medicaid Passengers Transportation of Passengers Total Intrastate Mileage American LegalNet, Inc. www.FormsWorkflow.com Income Statement Operating Revenues: 1. Household Goods revenue $____________________ 2. Passenger revenue $____________________ 3. Other operating revenue $____________________ 4. Rents received $____________________ 5. $____________________ Total Operating Revenue (Add Lines 1 through 4) Operating Expenses: 6. Repair & Servicing of equipment $____________________ 7. Tires & tubes $____________________ 8. Drivers’ & helpers’ wages $____________________ 9. Gasoline & oil 10. Other transportation expenses 11. Station & terminal expenses 12. Advertising & traffic expenses $____________________ $____________________ $____________________ $____________________ 13. Insurance $_____________________ 14. Office salaries & expenses $_____________________ 15. Taxes & Licenses $_____________________ 16. Rent Paid $ ____________________ 17. Depreciation $_____________________ 18. Total Operating Expenses (Add Line 6 through Line 17) $_____________________ Net Operating Revenue (Subtract Line 5 from Line 18) $_____________________ Other Income and Expenses: 20. Miscellaneous Income 21. Non-operating expenses Net Income (Add Line 19 and Line 20 then subtract Line 21) $____________________ $____________________ $_____________________ American LegalNet, Inc. www.FormsWorkflow.com Balance Sheet Assets: 1. Cash $_______________________ 2. Notes Receivable & Investments $_______________________ 3. Accounts Receivable $_______________________ 4. Prepayments $_______________________ 5. Materials & Supplies $_______________________ 6. Plant & Equipment $_______________________ 7. Less: Allowance for Depreciation $_______________________ 8. Organization, Certificates, Permits $_______________________ 9. Total Assets (Add Lines 1 through 8) $_______________________ Liabilities and Equity 10. Notes & Mortgages Payable $_______________________ 11. Accounts Payable $_______________________ 12. Salaries & Wages Payable $_______________________ 13. Accrued Taxes & Other Expenses $_______________________ 14. Capital Stock $_______________________ 15. Sole Proprietorship $_______________________ 16. Partnership $_______________________ 17. Surplus of Deficit $_______________________ 18. Total Liabilities (Add Lines 10 through 17) $_______________________ American LegalNet, Inc. www.FormsWorkflow.com Instructions GENERAL: The income and expenses shown in the income statement should include only those arising from motor carrier operations. Do not include income or expenses of your household, farm or other business or property. performing a portion of the carrier’s traffic haul; uniforms for employees, fines for traffic violations and similar items; and meals and lodging paid for employees while away from home. Income Statement OPERATING REVENUE: 1. Household Goods Revenue: Include the total amount of revenues earned in the transportation of household goods. 11. Station & Terminal Expenses: Include salaries and expenses incurred in the maintenance and operation of stations or terminals; commission’s payable to ticket agents and amounts payable to terminal companies and others for handling, billing, accounting and other station and terminal services; cost of operating collection and delivery equipment; and payment to others for performing this service. 12. Advertising & Traffic Expenses: Include salaries and expenses of employees engaged in solicitation of traffic; cost of advertising and other traffic expenses such as costs of tariffs and schedules, ticket and baggage checks, membership fees; and traffic or tariff associations, and other similar expenses. 13. Insurance: Include the cost of all insurance premiums paid or payable; insurance and safety expenses incurred in connection with the operations of the business; and amount of claims paid or payable when not covered by insurance. 14. Tires & Tubes: Include the amounts expended for tires and tubes, also amounts payable for the use of tires as a flat per period, per mile run, or similar basis, if such arrangement is in use. Office Salaries & Expenses: Include all office expenses, including salaries of office employees, the cost of office forms, shipping orders, bills of lading, freight bill or other waybill forms, binders, stationery and supplies, telephone and other communication services, legal, and other office expenses. 15. Taxes & Licenses: Include all taxes and license fees payable in connection with the operation of business, except federal income tax. 8. Drivers’ & Helpers’ Wages: Include the wages payable to drivers and helpers of motor vehicles. 16. Rents Paid: Include all rents payable for garage, station, terminal, office or other space used in motor carrier operations, and rent paid for use of equipment. 9. Gasoline & Oil: Include the cost of gasoline or other fuel and oil necessary to operate the motor carrier service. For the purpose of this system of accounts, taxes on gasoline and oil are considered part of the cost of gasoline or oil. 17. 10. Other Transportation Expenses: Include all other expenses incurred in connection with the furnishing of transportation service such as the cost of ropes, skids, skates, tarpaulins, and other miscellaneous supplies for buses and trucks; bridge, Depreciation: Include the amount you estimate to be the loss of value for the year for all your buildings and equipment used in the transportation business (but not your own residence) due to ordinary wear and tear which is not, or cannot be restored by maintenance. 2. Passenger Revenue: Include all revenues earned from the transportation of passengers. 3. Other Operating Revenue: Include all other incidental earnings from transportation services. 4. Rents Received: Include rents received for equipment and other property. 5. Total Operating Revenues: The total of lines 1 through 4. OPERATING EXPENSES: 6. 7. Repair & Servicing of Equipment: Include the cost of the parts and materials used, labor employed, and bills payable for repairing, greasing, washing and storing vehicles, including replacement of lights, batteries, horns, tire chains, and all other equipment of the vehicle, and repairs and maintenance of shop and garage buildings, grounds and equipment (including light, heat, power and water). American LegalNet, Inc. www.FormsWorkflow.com 4 years 6 years 6 years 4 years 40 years 6. Plant & Equipment: This account will consist of the gross cost of all equipment used in your operation. Include the cost of any improvements, repairs and overhauling of the plant and equipment necessary to outfit them for service. Allowance for Depreciation: This account will contain accumulated depreciation charged to the depreciation expense on income statement. 8. Organization Certificates & Permits: The amount to be reported represents the cost of obtaining certificate, permit and incorporation. Notes & Mortgages Payable: Include the face value of the outstanding obligations present at the end of the accounting period. 11. 18. 10 years - Materials & Supplies: Include the costs of all unapplied materials and supplies such as tools, repair parts, fuel, tires and tubes, etc., used in your operation. 10. Trucks and tractors Trailers Buses Automobiles Buildings Office Equipment Shop and Garage, misc. 5. 7. The amount of depreciation to be taken may be determined by dividing the original cost by the expected useful life. If a method of determining depreciation has been worked out which is satisfactory to the Internal Revenue Service for income tax purposes, the amount so used will be satisfactory to the Department. If no such rates have been established, and unless your own experience shows that some other rate should be used, the following rates will be satisfactory: Accounts Payable: Include the total amount payable in the affiliated companies, officers, stockholders, employees and others. 12. Salaries & Wages Payable: Include the amount of wages payable or accrued payrolls. 13. Accrued Taxes & Other Expenses: Include all taxes and other expenses accrued at the end of the period. 14. Capital Stock: (To be completed by corporations only.) Include the total par value of outstanding capital stock and the cash value of no par stock. 15. Sole Proprietorship: (To be used by a solely owned business.) Include the amount invested in a business by the proprietor at the beginning of the year; the amount of any additional investments into the business made by the proprietor during the year; the amount of proprietor withdrawal during the year; and the net profit or loss for the year. 16. Partnership: (To be used by partnerships and other forms of organizations other than corporations and sole proprietorship.) Include the amount invested in the business by the partners, or members of other forms of organizations, at the beginning of the year; the amount of any additional investments into the business made by the partner withdrawal during the year; and the net profit or loss for the year. 17. Surplus or Deficit: (To be used by corporation only.) Include the profit or loss accumulated at the end of the period, and all other surplus arising from donations by stockholders of cash and other assets or surplus for forgiveness of debt of the carrier by its stockholders. 10 years Total Operating Expenses: Add lines 6 through 17. OTHER INCOME AND EXPENSES: 20. 21. Miscellaneous Income: Include all other income earned from sources directly connected with motor carrier operations, such as interest on notes and open accounts, dividend, received from stocks of other transportation companies, commission’s received, etc. Non-Operating Expenses: Include all expenses incurred which do not directly pertain to the furnishing of motor carrier transportation service, such as interest paid on money borrowed for use in the business, federal and state income taxes, and similar items. Balance Sheet 1. Cash: Include all cash available for general business purposes. Include deposits in bank and savings accounts. 2. Notes Receivable & Investments: Include all collectible obligations payable to you, the book cost of investments and securities, and notes of other companies or persons. 3. Accounts Receivable: Include amounts currently due from customers, officers, stockholders and employees. 4. Prepayments: Include expenses paid or incurred in advance, the benefits of which will be realized in subsequent periods. Prepayment of minor items may be charged directly to the appropriate expense account. American LegalNet, Inc. www.FormsWorkflow.com