Schedules 1A, 2A and 3A SF# 49083 (R4 / 12-08) Transporter Schedule of Deliveries License Holder License Number Schedule Type (Check One) □ 1A Exports □ 2A Imports □ 3A In-State Transfers Person Hiring the Carrier (1) Name 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see the product code matrix on the Web site at www.in.gov/dor/reference/files/code-matrix.pdf Seller Information (Fuel Withdrawn From) (2) FEIN Month / Year Fein (3) Name (4) FEIN Delivered to (5) Mode (6) State of Origin (7) Name (8) FEIN (9) (10) (11) Destination Document Document State Date Number (12) Gross Gallons (14) (13) Import Billed or Verification Net Number Gallons Total American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com Column 7, 8 and 9: Enter the name, Federal Identification Number (FEIN - you may need to contact the shipper or person hiring you as the carrier if you are acting in the capacity of a common carrier for this information), and address of the company to which the product was delivered (final delivery point). Destination state should be included. You are not required to provide identification numbers (Column 8) for deliveries of home heating fuel to residential customers. Column 12: Enter the amount of gross gallons as shown on the shipping document. Column 1 and 2: Enter the name, address and Federal Identification Column 13: Enter the amount of billed or net gallons as shown on the Number (FEIN) of the person hiring the transporter. If you are transport- shipping document. ing your own fuel, then enter your company’s name and FEIN. Column 14: Enter the Import Verification Number (if applicable) as shown on the shipping document. Note: Per Indiana Code 6-6-2.5-62 Column 3 and 4: Enter the name, address and Federal Identification it is unlawful for a transporter to bring into Indiana, on behalf of an Number (FEIN) of the company selling the special fuel. This should importer, taxable fuel unless an import verification number has been be the company name and location from which the fuel was actually obtained. A person who knowingly violates or knowingly aids and abets withdrawn. another person in violating this subsection commits a Class D felony. Important: Please do not use any forms not approved by the Indiana Example: Webb Oil (a non-licensed entity) contacts Eaton Transport Department of Revenue. to pick up fuel from ABC Company (From whose account storage the fuel was withdrawn) to be delivered to Webb Oil’s customer Beverly Oil in Greenwood, Indiana. Note: When a transport load is split between more than one customer, you must indicate each delivery as a separate line item. Schedule 2A: Imports: This schedule must be completed when transporting fuel from a point outside of Indiana to a point inside Indiana. This reporting requirement includes all vehicles, regardless of capacity. Each load/delivery imported must be listed regardless of the number of gallons. Carry the totals from Schedule(s) 2A, Column Column 10: Enter the date the product was delivered as shown on 13 to Line 2 of SF-401. the document issued at the terminal when product is removed over the Schedule 3A: In-State Transfers: This schedule must be completed rack. In the case of pipeline or barge movements, enter the date shown when transporting fuel from a point starting inside Indiana to a point on the pipeline or barge ticket. If the fuel is from a bulk plant facility, ending in Indiana. This reporting requirement is not required for vehicles enter the date shown on the load or delivery ticket issued by the bulk with a capacity of less than 5,400 gallons. Each load/delivery imported plant operator. in a vehicle over 5,400 gallons must be listed regardless of the number of gallons imported. Carry the totals from Schedule(s) 3A, Column Column 11: Enter the identifying number from the document issued at the terminal when product is removed over the rack. In the case of 13 to Line 3 of SF-401. pipeline or barge movements, enter the pipeline or barge ticket number. If the fuel is from a bulk plant facility, enter the identifying number from Column Instructions: the load or delivery ticket issued by the bulk plant operator. Carry the totals from Schedule(s) 1A, Column 13 to Line 1 of SF-401. Webb Oil “Person Hiring Carrier” Columns 1 & 2 Person Filing the SF-401 Enter your identifying information as it is reflected on your Indiana Eaton Transport Transporter’s License. Check the appropriate schedule type that you Complete Indentifying Information at Top of Schedule are completing as well as the product type, and complete a separate ABC Company “Seller” (Fuel Withdrawn From) Columns 3 & 4 schedule for each fuel product type. Beverly Oil “Person Delivered To” Columns 7, 8 & 9 Schedule 1A: Exports: This schedule must be completed when transporting fuel from a point inside Indiana to a point outside of Indiana. This reporting requirement is not required for exports delivered Column 5: Enter the mode of transportation used to transport the by vehicles with a capacity of less than 5,400 gallons. Exports in product: vehicles with a capacity greater than 5,400 gallons should be reported J= Truck PL= Pipeline as follows: R= Rail B= Barge ST= Stock Transfer BA= Book Adjustment 1) Loads/Deliveries to a single location greater than 500 gallons must S= Ship (Great Lakes or Ocean Marine Vessel) be itemized on Schedule 1A. All information must be completed for each of these transactions. Column 6: State of Origin: Enter the state from which the product was 2) Loads/Deliveries to a single location of 500 gallons or less may be transported. If the product was loaded at a terminal, enter the terminal code assigned to that terminal. grouped together and reported as “VARIOUS”. Before You Begin: Instructions for Completing Schedule of Deliveries Schedules 1A, 2A and 3A