Facility Information
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Facility Information Form. This is a Indiana form and can be use in Department Of Revenue Statewide.
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Tags: Facility Information, HC-500 Schedule B, Indiana Statewide, Department Of Revenue
HC-500 Schedule B
(R2 / 11-07)
Indiana Department of Revenue
Facility Information
Facility Name
Facility Address or Location
City
Phone Number
State
(
Zip Code
)
County
Title III ID # (issued by IDEM)
Category Code (Check 1 box only)
A ($200.00)
B ($100.00)
C ($50.00)
New Facility
Exempt
Existing Facility Omitted from Schedule A
Facility Name
Facility Address or Location
City
Phone Number
State
(
Zip Code
)
County
Title III ID # (issued by IDEM)
Category Code (Check 1 box only)
A ($200.00)
B ($100.00)
C ($50.00)
New Facility
Exempt
Existing Facility Omitted from Schedule A
Facility Name
Facility Address or Location
City
Phone Number
State
(
Zip Code
)
County
Title III ID # (issued by IDEM)
Category Code (Check 1 box only)
A ($200.00)
B ($100.00)
C ($50.00)
New Facility
Exempt
Existing Facility Omitted from Schedule A
Facility Name
Facility Address or Location
City
Phone Number
State
(
Zip Code
)
County
Title III ID # (issued by IDEM)
Category Code (Check 1 box only)
A ($200.00)
B ($100.00)
C ($50.00)
New Facility
Exempt
Existing Facility Omitted from Schedule A
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