Schedule 11 SF# 49085 (R3/ 12-08) Schedule of State Diversion Corrections Supplier Name License Number Month / Year Fein You may photocopy this blank schedule for future filings. Attach additional sheets if necessary. Please see the product code matrix on the Web site at www.in.gov/dor/reference/files/code-matrix.pdf Carrier Information (1) Carrier Name (2) Carrier FEIN (4) (3) Original Mode Dest. State Revised Dest. State Purchaser Information (5) Terminal Code (6) Purchaser Name (7) Purchaser FEIN (8) Date Shipped (10) (9) Net Document Number Gallons (11) Gross Gallons (12) Billed Gallons (13) Diversion Number Total American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com Note: All loads of diverted fuel are to be reported on this schedule. This includes tax paid purchases diverted to out-of-state locations and imports into Indiana from another state, tax unpaid. Enter your identifying information as it is reflected on your Indiana Special Fuel License. Be certain to complete a separate schedule for each fuel product type that you circle. Before You Begin: The diversion is to be reported by the company diverting the fuel. The “diversion number” must be obtained before the diversion occurs. To obtain diversion numbers, contact www.fueltrac.us. Failure to comply may result in penalties including fines and/or impoundment, seizure and subsequent sale of your cargo. Columns 1 and 2: Enter the name and Federal Identification Number (FEIN) of the company that transports the fuel. This may be you. All special fuel transported in a motor vehicle with a capacity of more than five thousand four hundred (5,400) gallons must be accompanied by a machine printed shipping paper/bill of lading which includes the 1) name of the seller, 2) name of the purchaser, 3) type of fuel transported, 4) amount of fuel transported, 5) origin state and destination state of the load, 6) whether the fuel is dyed or undyed, and 7) if the destination state is Indiana, the document must state on its face the following: “Indiana special fuel tax billed or collected by supplier or Indiana special fuel tax billed or collected by permissive supplier” or similar wording that has been approved by the Department. Anytime an incorrect shipping paper has been issued or fuel is diverted from the original destination state, a “diversion number” must be obtained from Fuel Trac. The diversion number and the corrected information must then be entered on the shipping paper before the fuel can be transported. This schedule should reflect all loads of fuel that have been diverted during the reporting period. J = Truck P L = Pipeline R = Rail B = Barge ST = Stock Transfer BA = Book Adjustment S = Ship (Great Lakes or Ocean Marine Vessel) Column 13: Enter the diversion number assigned to you by Fueltrac. If you have not obtained a diversion number for each entry, contact Fuel Trac for further assistance. Column 12: Enter the billed (invoiced) gallons. This should equal either the net or the gross gallons. Column 11: Enter the gross gallons. Column 10: Enter the net gallons. Columns 6, 7, 8, and 9: Enter the purchaser’s information, the date shipped, and the document number. Invoice numbers cannot be used in lieu of bill of lading or manifest number. Column 5: Enter the terminal code number assigned by the IRS or BULK for bulk storage or BIO for biodiesel. Column 4: Enter the original destination state as printed on the manifest or bill of lading and the state to which the fuel is being diverted. Column 3: Enter the mode of transport. One of the following codes should be used for each entry Column Instructions: Who Should File This Schedule? Instructions for Completing Schedule of Diversions Schedule 11