Form GT-103DR (State Form 55500) "Recap of Gasoline Use Tax by Distributors" - Indiana

What Is Form GT-103DR (State Form 55500)?

This is a legal form that was released by the Indiana Department of Revenue - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Indiana Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form GT-103DR (State Form 55500) by clicking the link below or browse more documents and templates provided by the Indiana Department of Revenue.

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Download Form GT-103DR (State Form 55500) "Recap of Gasoline Use Tax by Distributors" - Indiana

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Indiana Department of Revenue
Form
GT-103DR
Recap of Gasoline Use Tax by Distributors
State Form 55500
For the Month of: ____________________
(R3 / 7-21)
Important: This form must be filed even when no transactions have occurred.
Taxpayer Information
Taxpayer Name
DBA
Taxpayer Identification Number (TID)
Street Address
Federal Identification Number (FID)
City or Town
State
ZIP Code
Telephone Number
Gallon Summary
Receipts - Schedule 1
Total Gallons Purchased
Gasoline Use Tax Paid
Gasoline
Gasohol
Total Gallons of Fuel Purchased
Disbursements - Schedule 2
Total Gallons Sold
Total Exempt
Gasoline Use
Gallons Sold
Tax Collected
Gasoline
Gasohol
Total Gallons of Fuel Sold
Printed Name: _______________________________________
Title: _____________________________________
Signature: __________________________________________
Date: ________________________
For questions contact the department at:
(317) 615-2630
fetax@dor.in.gov
Indiana Department of Revenue
Form
GT-103DR
Recap of Gasoline Use Tax by Distributors
State Form 55500
For the Month of: ____________________
(R3 / 7-21)
Important: This form must be filed even when no transactions have occurred.
Taxpayer Information
Taxpayer Name
DBA
Taxpayer Identification Number (TID)
Street Address
Federal Identification Number (FID)
City or Town
State
ZIP Code
Telephone Number
Gallon Summary
Receipts - Schedule 1
Total Gallons Purchased
Gasoline Use Tax Paid
Gasoline
Gasohol
Total Gallons of Fuel Purchased
Disbursements - Schedule 2
Total Gallons Sold
Total Exempt
Gasoline Use
Gallons Sold
Tax Collected
Gasoline
Gasohol
Total Gallons of Fuel Sold
Printed Name: _______________________________________
Title: _____________________________________
Signature: __________________________________________
Date: ________________________
For questions contact the department at:
(317) 615-2630
fetax@dor.in.gov