HC-2 Indiana Department of Revenue Hazardous Chemical Change of Ownership Form State Form 51228 (R3 / 3-09) This form is to be used if you sold a facility or facilities during the previous year. The legal owner of the facility as of Dec. 31 of the previous year should file this form. Anyone who owned a facility that stored extremely hazardous chemical substances in a quantity above the Threshold Planning Quantity (TPQ) or 500 pounds, whichever is less, or a facility where hazardous chemicals were stored in a quantity of 10,000 pounds or above, is responsible for the yearly fee. This fee is not prorated and payment must be sent in with Form HC-500. Owner’s Invoice Number Previous Facility Owner’s Information Date of Ownership Federal I.D. Number/Social Security Number Previous Owner’s Name (The company or individual who owns the facility) Previous Owner’s Physical Address (Not a P.O. Box) Date Facility Sold City State Zip Code Facility I.D. Number Current Facility Owner’s Information New Owner’s Name (The company or individual who owns the facility, not a leaseholder or contract buyer) New Owner’s Physical Address (Not a PO Box) Date Facility Bought City Facility I.D. Number State Zip Code Federal I.D. Number New Owner’s Name (The company or individual who owns the facility, not a leaseholder or contract buyer) New Owner’s Physical Address (Not a P.O. Box) Date Facility Bought City Facility I.D. Number State Zip Code Federal I.D. Number New Owner’s Name (The company or individual who owns the facility, not a leaseholder or contract buyer) New Owner’s Physical Address (Not a P.O. Box) Date Facility Bought City Facility I.D. Number State Zip Code Federal I.D. Number Under penalty of perjury, I have examined this return (including accompanying schedules and statements) and to the best of my knowledge and belief it is true, complete and correct. Owner’s Signature: Date: Print or Type Name: Title: Telephone Number: Please submit this form along with the HC-1 (Hazardous Chemical Fee Change Form) and Form HC-500 Mail the Completed Forms and Fee To: Indiana Department of Revenue Excise Tax Section: Environmental, HC-500 100 N. Senate Avenue Indianapolis, IN 46204-2253 American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing the HC-2 Hazardous Chemical Change of Ownership Form Who should file this form? The legal owner of the facility as of Dec. 31 of the previous year should file this form. Anyone who owned a facility that stored extremely hazardous chemical substances in a quantity above the Threshold Planning Quantity (TPQ) or 500 pounds, whichever is less, or a facility where hazardous chemicals were stored in a quantity of 10,000 pounds or above, is responsible for the yearly fee. This fee is not prorated and payment must be sent in with Form HC-500. Owner’s Invoice Number The Indiana Department of Revenue assigns this number to each owner who files an HC-500. Date of Ownership Enter the date you assumed legal ownership. Federal Identification Number (FID) / Social Security Number (SSN) The Indiana Department of Revenue cannot process any form that does not contain a valid FID or SSN. Previous Owner’s Name Enter the name of the individual or company who legally owned the facility prior to sale. Previous Owner’s Physical Address The prior legal owner of a facility must enter the owner’s physical address. (Not a PO Box) Date Sold Enter the date the buyer assumed legal possession of the facility. Facility I.D. Number(s) Enter the facility I.D. number that was assigned by the Indiana Department of Environmental Management (IDEM) for each facility that has been sold. Attach additional sheets if necessary. New Owner’s FID/SSN Enter the Federal Identification Number or Social Security Number. New Owner’s Name Enter the name of the individual or company who currently legally owns the facility, not a leaseholder or contract buyer. New Owner’s Physical Address The current legal owner of a facility must enter the owner’s physical address. (Not a P.O. Box) Signature, Date, Title and Telephone Number The Indiana Department of Revenue cannot process any form not signed by the company’s owner or responsible officer. For questions concerning your facility or category, contact the Indiana Department of Environmental Management at (317) 233-0066. For questions concerning payment, contact the Indiana Department of Revenue at (317) 615-2544. Please submit this form along with the HC-1 (Hazardous Chemical Fee Change Form) and Form HC-500 Mail the Completed Forms and Fee To: Indiana Department of Revenue Excise Tax Section: Environmental, HC-500 100 N. Senate Avenue Indianapolis, IN 46204-2253 American LegalNet, Inc. www.FormsWorkflow.com