State Form 49875 Form Mf-360x - Amended Consolidated Gasoline Monthly Tax Return - Indiana

Form State49875 is a Indiana Department of Revenue form also known as the "Form Mf-360x - Amended Consolidated Gasoline Monthly Tax Return". The latest edition of the form was released in April 6, 2018 and is available for digital filing.

Download a PDF version of the Form State49875 down below or find it on Indiana Department of Revenue Forms website.

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Indiana Department of Revenue
Mailing/Contact Information:
Form
Indiana Department of
MF-360X
Amended Consolidated Gasoline Monthly Tax Return
Revenue
State Form 49875
Due date is the 20th of the following month.
Special Tax Division
(R6 / 4-18)
P.O. Box 6080
For the month of:_________________ 20_____
Indianapolis, IN 46206-6080
(317) 615-2630
fetax@dor.in.gov
Name of License Holder (as indicated on license)
License Number (as indicated on license)
Mailing Address
FEIN/SSN
City
State
ZIP Code
Business Phone Number Contact Name
Section 1: Filing Types
This is a consolidated return for all license types listed below. Place an “X” in the box to the left of each license type for which you are
licensed.
Gasoline
Oil Inspection Distributor
Gasohol Blender
A
B
C
Previously
Amount of
Current
Reported
Change
Amount
Amount
Section 2: Calculation of Gasoline Taxes Due
1 Total receipts (From Section A, Line 8, Column D)
1
2 Total non-taxable disbursements (From Section B, Line 10,
Column D)
2
3 Gallons received, gasoline tax paid (From Section A, Line 1,
Column A)
3
4 Billed taxable gallons (Line 1 minus Line 2 minus Line 3)
4
5 Licensed gasoline distributor deduction (Multiply Line 4 by 0.016)
5
6 Billed taxable gallons (Line 4 minus Line 5)
6
7 Gasoline tax due (Multiply Line 6 by the applicable rate, see
instructions)
7
8 Adjustments (Schedule E-1 must be attached and is subject to
department approval)
8
9 Total gasoline tax due (Line 7 plus or minus Line 8)
9
Section 3: Calculation of Oil Inspection Fees Due
1 Total receipts (From Section A, Line 9, Column D)
1
2 Total non-taxable disbursements (From Section B, Line 11,
Column D)
2
3 Gallons received, oil inspection fee paid (From Section A, Line 1,
Column D)
3
4 Billed taxable gallons (Line 1 minus Line 2 minus Line 3)
4
5 Oil inspection fees due (Multiply Line 4 by $0.01)
5
6 Adjustments (Schedule E-1 must be attached and is subject to
department approval)
6
7 Total oil inspection fees due (Line 5 plus or minus Line 6)
7
Indiana Department of Revenue
Mailing/Contact Information:
Form
Indiana Department of
MF-360X
Amended Consolidated Gasoline Monthly Tax Return
Revenue
State Form 49875
Due date is the 20th of the following month.
Special Tax Division
(R6 / 4-18)
P.O. Box 6080
For the month of:_________________ 20_____
Indianapolis, IN 46206-6080
(317) 615-2630
fetax@dor.in.gov
Name of License Holder (as indicated on license)
License Number (as indicated on license)
Mailing Address
FEIN/SSN
City
State
ZIP Code
Business Phone Number Contact Name
Section 1: Filing Types
This is a consolidated return for all license types listed below. Place an “X” in the box to the left of each license type for which you are
licensed.
Gasoline
Oil Inspection Distributor
Gasohol Blender
A
B
C
Previously
Amount of
Current
Reported
Change
Amount
Amount
Section 2: Calculation of Gasoline Taxes Due
1 Total receipts (From Section A, Line 8, Column D)
1
2 Total non-taxable disbursements (From Section B, Line 10,
Column D)
2
3 Gallons received, gasoline tax paid (From Section A, Line 1,
Column A)
3
4 Billed taxable gallons (Line 1 minus Line 2 minus Line 3)
4
5 Licensed gasoline distributor deduction (Multiply Line 4 by 0.016)
5
6 Billed taxable gallons (Line 4 minus Line 5)
6
7 Gasoline tax due (Multiply Line 6 by the applicable rate, see
instructions)
7
8 Adjustments (Schedule E-1 must be attached and is subject to
department approval)
8
9 Total gasoline tax due (Line 7 plus or minus Line 8)
9
Section 3: Calculation of Oil Inspection Fees Due
1 Total receipts (From Section A, Line 9, Column D)
1
2 Total non-taxable disbursements (From Section B, Line 11,
Column D)
2
3 Gallons received, oil inspection fee paid (From Section A, Line 1,
Column D)
3
4 Billed taxable gallons (Line 1 minus Line 2 minus Line 3)
4
5 Oil inspection fees due (Multiply Line 4 by $0.01)
5
6 Adjustments (Schedule E-1 must be attached and is subject to
department approval)
6
7 Total oil inspection fees due (Line 5 plus or minus Line 6)
7
A
B
C
Previously
Amount of
Current
Reported
Change
Amount
Amount
Section 4: Calculation of Total Amount Due
1 Total amount due (Section 2, Line 9 plus Section 3, Line 7)
1
2 Penalty (Penalty must be added if report is filed after the due date.
10% of tax due or $5.00, whichever is greater.)
2
3 Interest (Interest must be added if report is filed after the due date.)
3
4 Net tax due (Line 1 plus Line 2 plus Line 3)
4
5 Payment(s)
5
6 Balance due (Line 4 minus Line 5)
6
7 Gallons of gasoline sold to taxable marina
7
Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best
of my knowledge and belief it is true, correct, and complete.
Signature of Taxpayer or Authorized Agent: ____________________________________
Date:_____________________________
Typed or Printed Name: _____________________________
Title: __________________
Phone Number: __________________
Email Address: ____________________________________
Enter the corrected total amount of gallons on this page.
A
B
C
D
From
Gasoline/Aviation
K-1/K-2
All Other
Totals
Section A: Receipts
Schedule
Gasoline/Gasohol
Kerosene
Products
1 Gallons received, excise tax paid
1A
2 Gallons received from licensed distributors or oil inspection distributors, tax
unpaid
2
3 Gallons of non-taxable fuel received and sold or used for a taxable purpose
2K
4 Gallons received from licensed distributors on exchange agreements, tax unpaid
2X
5 Gallons imported directly to customer
3
6 Gallons imported into own storage
4
7 Diversions into Indiana
11
8 Total receipts - add Lines 1-7, carry total (Column D) to Section 2, Line 1
9 Total receipts - add Lines 1-7, carry total (Column D) to Section 3, Line 1
A
B
C
D
From
Gasoline/Aviation
K-1/K-2
All Other
Totals
Section B: Disbursements
Schedule
Gasoline/Gasohol
Kerosene
Products
1 Gallons delivered, tax collected
5
2 Diversions out of Indiana
11
3 Gallons sold to licensed distributors, tax not collected
6D
4 Gallons disbursed on exchange
6X
5 Gallons exported
7
6 Gallons delivered to U.S. Government - tax exempt
8
7 Gallons delivered to licensed marina fuel dealers
10A
8 Gallons delivered to licensed aviation fuel dealers
10B
9 Miscellaneous deduction - theft/loss
E-1
9a Miscellaneous deduction - off road, other
E-1
10 Total non-taxable disbursements - add Lines 2-9a, carry total to Section 2, Line 2
11 Total non-taxable disbursements - add Lines 2-6, carry total to Section 3, Line 2
Instructions for completing Consolidated Gasoline Monthly Tax Return (MF-360X)
Who should file this return?
Amount Due: If Section 4, Column C, Line 4 is greater than
Section 4, Column C, Line 5, you owe additional tax. Enter this
You should file this form if you are an Indiana licensed gasoline
amount of tax due in Section 4, Column C, Line 6. Note: The
distributor, oil inspection distributor, or gasohol blender and
amount of tax you owe must include penalty and interest due on
you need to amend or change a previously filed Consolidated
late payments. Be certain you have completed Section 4, Column
Gasoline Monthly Tax Return, Form MF-360. If you have made
C, Lines 2 & 3, to reflect any penalty and interest due.
a calculation error on your return you do not need to file an
amendment. The department will make changes for you and will
If money is owed on an amended return you should subtract the
let you know the results.
amount of collection allowance from gallons amended.
Completing the Form
Refund Due: If Section 4, Column C, Line 4 is less than Section
4, Column C, Line 5, you are due a refund. Enter the amount of
You should refer to the instructions for your original Consolidated
your calculated refund in Section 4, Column C, Line 6 in brackets
Gasoline Monthly Tax Return, and related schedules, for the tax
(example). Sign your return, and ensure that it is mailed to us
period being amended.
and postmarked within the required statute of limitations period.
We will process your claim within 90 days of receipt, issue your
Enter your company’s identifying information on Form MF-360X
refund, or explain why your claim is denied or reduced.
and all accompanying schedules. Complete all information,
leaving nothing blank. It is critical that you use the same license
What is the Statute of Limitations
number on this report that is shown on your actual license. A
Period for Refunds?
separate MF-360X must be filed for each tax period requiring an
amendment.
Within three (3) years after the end of the calendar year
containing the taxable period in which the tax was erroneously
collected IC 6-6-1.1-907(b).
Gasoline Tax Rate Table
Transaction Date
Tax Rate
What if I Have Other Questions?
Periods prior to July 1, 2017
$0.18 per gallon
If you have other questions, contact our office by calling (317)
July 1, 2017 through June 30, 2018
$0.28 per gallon
615-2630. You may send us an email at fetax@dor.in.gov, or you
For periods on or after July 1, 2018
$0.29 per gallon
can also write to us at:
Section 1
Indiana Department of Revenue
Special Tax Division
Place an “X” in the box to the left of each license type for which
P.O. Box 510
you are licensed
Indianapolis, IN 46206-0510
Sections A & B
Correct all applicable receipt and disbursement schedules and
enter the amount of the corrected total gallons for each schedule
in Sections A & B on the reverse side of the MF-360X.
Sections 2, 3, & 4
Column A: Should reflect all amounts previously reported on your
original tax return, or a previously amended return. If a return has
been previously amended, Column A will be the amounts reported
in Column C of the previously filed amended return.
Column B: This column is the amount of change only. Use this
column to report changes in line amounts from those previously
reported. Changes in Column B must be documented by attaching
the corresponding schedules, as amended. If there is no change
to a particular line entry, enter zero.
Column C: This column is calculated by adding or subtracting the
amounts in Column B from the amounts entered in Column A. If
there is no change for a line in Column B, then carry the amount
from Column A to Column C for that line.

Download State Form 49875 Form Mf-360x - Amended Consolidated Gasoline Monthly Tax Return - Indiana

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