SF-900X SF# 47737 (R7 / 12-08) Indiana Department of Revenue Amended Consolidated Special Fuel Monthly Tax Return For the month of:______________ 20___ This amended report must be filed to correct any previous report with an error or omission. Name of License Holder (As indicated on license) License Number (As indicated on license) Mailing Address FEIN/SSN City or Town State Zip Code Business Telephone Number Contact Name ( ) Section 1: Filing Types This is a consolidated return for all license types listed below. Place an “X” in the box to the left of each license type for which you are licensed.  Supplier  Permissive Supplier  Blender  Dyed Fuel User  Exporter  Importer A As Reported or Last Determined Section 2: Computation of Tax 1. Total Receipts (From Section A, Line 5 on back of return) B Amount of Change Supporting Sched. Must be attached. C Current Amount 1. 2. Total Non-Taxable Disbursements (From Section B, Line 11 on back of return) + 3. Taxable Gallons Sold or Used (From Section B, Line 3, on back of return) - 2. 3. 4. Gallons Received Tax Paid (From Section A, Line 1, on back of return) 4. 5. Billed Taxable Gallons (Line 3 minus Line 4) 5. 6. Tax Due (Multiply Line 5 by $0.16) 6. 7. Amount of Tax Uncollectible from Eligible Purchasers - Complete Schedule 10E 7. 8. Adjusted Tax Due (Line 6 minus Line 7) 8. 9. Collection Allowance (Multiply Line 8 by .016). If return filed or tax paid after due date enter zero (0) 9. + 10. Adjustment - Complete Schedule E-1 (Dollar amount only) - 10. 11. Total special fuel tax due (Line 8 minus Line 9 plus or minus Line 10) 11. Section 3: Calculation of Oil Inspection Fees Due (For Periods Beginning after June 30, 2005 Only) 1. Total billed gallons (From Section 2, Line 5) 1. 2. Oil inspection fees due (Multiply Line 1 by $0.01) 2. 3. Adjustments(Schedule E-1 must be attached and is subject to Department approval) + - 4. Total oil inspection fees due (Line 2 plus or minus Line 3) Section 4: Calculation of Total Amount Due 1. Total amount due (Section 2, Line 11 plus Section 3, Line 4) 2 4. 1. (Penalty must be added if report is filed after the due date. 10% of tax due or $5.00, whichever is greater. Five dolPenalty lars ($5.00) is due on a late report showing no tax due.) 3. Interest (Interest must be added if report is filed after the due date. 3. Contact the Department for daily interest rates.) 2. 3. 4. Net tax due (Line 1 plus Line 2 plus Line 3) 4. 5. Payment(s) 5. 6. Balance due (Line 4 minus 5) For Department Use Only Check Amount: 6. Check Number: Under the penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. I further declare that complete and proper records are on file at the address indicated above for all fuel reported on this return. Taxpayer or Authorized Agent Typed or Printed Name Date Signed Date Business Closed / / ❑ Please Check Box If Last Filing Title Telephone Number ( ) Make check payable to Indiana Department of Revenue and mail to: P.O. Box 6080, Indianapolis, Indiana 46206-6080 ( Please include license number on check.) American LegalNet, Inc. www.FormsWorkflow.com A B As Reported or Last Amount of Change (Supporting Determined Schedule Must Be Attached) Use Whole Use Whole From Gallons Only Schedule Gallons Only Section A: Receipts C Current Amount Use Whole Gallons Only 1. Gallons Received Tax Paid (Carry forward to Section 2, Line 4 on front of return) 1 2. Gallons Received for Export (To be completed only by licensed exporters) 2E 3. Gallons of Nontaxable Fuel Received and Sold or Used For a Taxable Purpose 2K 4. 5. Gallons Imported Via Truck, Barge, or Rail, Tax Unpaid Total Receipts (Add Lines 1 through 4, carry forward to Section 2, Line 1 on front of return) Section B: 3 From Use Whole Schedule Gallons Only Disbursements 1. Gallons Delivered Tax Collected and Gallons Blended or Dyed Fuel Used 2. Diversions (Special fuel only) + Use Whole Gallons Only Use Whole Gallons Only 5 - 11 3. Taxable Gallons Sold or Used (Carry forward to Section 2, Line 3 on front of return) 4. Gallons Delivered Via Rail, Pipeline or Vessel to Licensed Suppliers, Tax Not Collected 6 5. Gallons Disbursed on Exchange for Other Suppliers or Permissive Suppliers 6X 6. Gallons Exported by License Holder 7 7. Gallons Sold to Unlicensed Exporters for Export 7A 8. Gallons Sold to Licensed Exporters for Export 7B 9. Gallons of Undyed Fuel Sold to the U.S. Government - Tax Exempt 8 10 10. Gallons Sold of Tax Exempt Dyed Fuel 11. Total Non-Taxable Disbursements (Add Lines 4 through 10; carry forward to Section 2, Line 2 on front of return) (Information Only) Reporting of IVP Numbers Given By the Department IVP Number IVP Payment IVP Number 1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. IVP Payment 12. American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Amended Consolidated Special Fuel Monthly Tax Return SF-900X Who should file this return? You should file this form if you are an Indiana licensed special fuel supplier, permissive supplier, exporter, importer, blender or dyed fuel user and you need to amend or change a previously filed Consolidated Special Fuel Monthly Tax Return, Form SF-900. Completing the Form Refund Due: If Column C, Section 4, line 4 is less than Column C, Section 4, line 5, you are due a refund. Enter the amount of your calculated refund in Column C, Section 4, line 6 in brackets [example]. Sign your return, and be sure that it is mailed and postmarked within the statute of limitations period. Your claim for refund will be processed within 90 days of receipt; your refund will be issued, or you will receive an explanation for why the refund was denied or reduced. You should refer to the instructions for your original Consolidated Special Fuel Monthly Tax Return, and * Licensed Indiana suppliers and permissive suppliers must make all payments by Electronic related schedules, for the tax period being amended. Funds Transfer. Enter your company’s identifying information on form What is the Statute of Limitations SF-900X and all accompanying schedules. Complete all Period for Refunds? information, leaving nothing blank. It is critical that you use the same license number on this report that is shown Generally, you have three (3) years from the date the on your actual license. A separate SF-900X must be filed fuel was purchased and the tax paid to claim a refund. for each tax period requiring an amendment. What if I Have Other Questions? Column A: Complete column A by entering the amounts as reported on your original tax return, or as previously amended. (If previously amended, column A will be the If you have other questions, contact our office by callamounts reported in column C of the previously filed ing (317) 615-2630. You may email us at fetax@dor.in.gov, or you can write to us at: amended return.) Column B: Use this column to report changes in line amounts from those previously reported. Changes in column B must be documented by attaching the corresponding schedules, as amended. If there is no change to a particular line entry, enter zero (-0-). Indiana Department of Revenue P.O. Box 6080 Indianapolis, IN 46206-6080 Column C: This column is calculated by changing the amounts reported in column A according to any changes made in Column B. All lines must be completed even if some lines do not change. Amount Due: If Column C, Section 4, line 4 is greater than Column C, Section 4, line 5, you owe additional tax. Enter this amount in Column C, Section 4, line 6. This is the amount of tax due. Caution: The amount of tax you owe should be increased by the penalty and interest due on late payments. Be certain you have completed Section 4, lines 2 and 3 to reflect any penalty and interest due.* American LegalNet, Inc. www.FormsWorkflow.com