HC-1 Indiana Department of Revenue State Form 51229 Hazardous Chemical Fee Change Form (R3 / 3-09) This form is to be used when the fee paid to the Indiana Department of Revenue is different than what is listed on the HC-500. Failure to provide this information could result in penalty and interest charges. The Indiana Department of Revenue cannot process any form that does not contain a Federal Identification Number or a Social Security Number and a signature of the company owner or responsible officer. Owner’s Name Federal Identification Number Owner’s Physical Address (Not a PO Box) Social Security Number City State Zip Code Owner’s Invoice Number 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. Facility I.D. Number Ownership Date Category Date Closed/Sold Under penalty of perjury, I have examined this return (including any accompanying schedules and statements) and to the best of my knowledge and belief it is true, complete and correct. Owner’s Signature: Print or Type Name: Telephone Number: Date: Title: Please submit this completed form with Form HC-500 and mail 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-1 Hazardous Chemical Fee Change 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 Name Enter the name of the individual or company who legally owns the facility. Owner’s Physical Address The legal owner of a facility must enter the owner’s physical address. (Not a P.O. Box) 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. Owner’s Invoice Number The Indiana Department of Revenue assigns this number to each owner who files an HC-500. Facility Identification Number Enter the facility number that was assigned by the Indiana Department of Environmental Management (IDEM). Date of Ownership Enter the date you assumed legal ownership of the facility. Category Enter the letter for the appropriate category. Only one category will apply to a facility: (A) Any single hazardous chemical substance 1,000,000 pounds or more (B) Any single hazardous chemical substance less than 1,000,000 pounds (C) Underground storage tanks only -or(E) Exempt Date Closed/Sold Enter the date the facility closed or the date the current owner assumed legal possession of the facility. If you sold a facility prior to Dec. 31 of the previous year, please complete the HC-2 Hazardous Chemical Change of Ownership form and submit it with Form HC-500. 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. Please submit this completed form with Form HC-500 and mail to: Indiana Department of Revenue Excise Tax Section: Environmental, HC-500 100 N. Senate Avenue Indianapolis, IN 46204-2253 For Questions related to your facility or category, contact the Indiana Department of Environmental Management, (317) 233-0066. For questions related to this form, contact the Indiana Department of Revenue, (317) 615-2544. American LegalNet, Inc. www.FormsWorkflow.com