Indiana Department of Revenue SF-401X Amended Transporter's Monthly Tax Return SF# 47735 (R2/05-07) For the month of: _________________ 20______ Gallons as Amended Name of License Holder (As indicated on License) Mailing Address (Street or P.O. Box Number) City or Town State Zip Code License Number Telephone Number Federal Identification Number Motor Carrier/IFTA Number Gallons as Previously Reported From Schedule 1. 2. 3. 4. Total gallons of fuel loaded from an Indiana terminal or bulk plant and delivered to another state. Gallons as Amended Column C Column A Other Products Special Fuel (Dyed and Clear (Jet Fuel, Diesel Fuel, Kerosene) Biodiesel and Blended Biodiesel) Column B Gasoline (Gasoline, Gasohol) Column C Other Products (Jet Fuel, Kerosene) 2A Total gallons of fuel loaded from an Indiana terminal or bulk plant and delivered within Indiana. (Dyed and Clear Diesel Fuel, Biodiesel and Blended Biodiesel) Column B Gasoline (Gasoline, Gasohol) 1A Total gallons of fuel loaded from an out-of-state terminal or bulk plant and delivered into Indiana. Column A Special Fuel 3A Total gallons of fuel transported. (Add lines 1, 2, and 3). Transporter's Schedule of Deliveries Schedules 1A, 2A and 3A must be attached to this report Mail Return To: Indiana Department of Revenue, P.O. Box 6080, Indianapolis, IN 46206-6080 Under 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 adress indicated above for all fuel reported on this return. Taxpayer or Authorized Agent Typed or Printed Name Title Date Signed Telephone Number ( ) Important! A return must be filed each month, within 25 days following the last day of the month being reported. Failure to submit this report could result in a civil penalty of $1,000 for each violation. American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Amended Fuel Transporter's Monthly Tax Return Schedule SF-401X Who should file this return? You should file this form if you are an Indiana Licensed Fuel Transporter and you need to amend or change a previously filed Fuel Transporter's Monthly Tax Return, Form SF-401. How do I complete the SF-401X? You should refer to the instructions for your original Fuel Transporter's Monthly Tax Return, and related schedules, for the tax period being amended. Gallons as Previously Reported Complete lines 1 through 4 of Column A, Column B and Column C by entering the amounts as reported on your original tax return, or as previously amended. (If previously amended, lines 1 through 4 will be the amounts reported in column titled "Gallons as Amended" of the previously filed amended return.) Gallons as Amended Use this column to report changes in line amounts from those previously reported. Changes in column titled "Gallons as Amended" must be documented by attaching the corresponding schedules, as amended. If there is no change to a particular line entry, enter zero. What if I have other questions? If you have additional questions, please contact our office by calling (317) 615-2630, or write to us at: Indiana Department of Revenue P.O. Box 6080 Indianapolis, IN 46206-6080 American LegalNet, Inc. www.FormsWorkflow.com