Form Bt-1 Sf 43760 - Business Tax Application - Indiana Department Of Revenue Page 4
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Business Tax Application
Page 4a
All retail merchants who are issued a permit to collect Prepaid Sales Tax on Gasoline
will be required to file monthly detailed reports (ST-103QD) with the Department.
A Prepaid Sales Tax Permit (BT-2) is not assignable and is valid only for the distributor in whose name it is issued.
Bonding Procedure
Concurrently with the filing of this application for a permit, a qualified distributor must file a bond with the Department. Below is the prescribed
formula for calculating the correct bond amount.
1.
Estimated average number of gallons supplied monthly from Section G, Line 3..........................
2.
Multiply Line 1 by .033 (Round to the nearest dollar amount)...................................................
3.
Estimated bond amount (multiply the amount on Line 2 by 3)....................................................
The amount on Line 3 is the amount of your bond, provided it is at least two thousand dollars ($2,000) which is the minimum bond amount. Indiana
Code 6-2.5-7-8 states that the Department shall determine the amount of the distributor's bond. Please use the most accurate figures available
to avoid a deficient bond. Please enclose Bond Form ST-160 or another form of surety and return it to the Department with this application.
In order to obtain a permit to collect Prepaid Sales Tax on Gasoline, the Indiana Department of Revenue requires that each refiner,
distributor or terminal operator agrees to make payment to the Department by means of "Electronic Funds Transfer" as defined in I.C.
4-8.1-2-7. An EFT authorization must be completed and returned to the Department. For further information regarding EFT filing,
and/or EFT authorization agreement contact the Department at (317) 232-5500.
Signature Section
Contact the Department at (317) 615-2700 for more information regarding this application.
I hereby certify that the statements are correct.
Signature: ______________________________________________________ Title: ___________________________________________
Date: ____________________________
This application must be signed by the owner, general partner, corporate officer, or resident agent before it will be accepted by the
Department. (I.C. 6-8.1-3-4)
NOTE: Failure to remit sales tax due and/or income tax withheld is a felony punishable by imprisonment, a fine of $10,000 plus a
100% fraud penalty.
The partners or corporate officers are each personally, jointly and severally liable for the sales and use tax* collected and the
withholding tax withheld. These taxes are trust fund taxes and are not discharged in bankruptcy proceedings.
*This includes:County Innkeepers Tax (CIT), Food and Beverage Tax (FAB), Prepaid Sales Tax, and Motor Vehicle Rental and County
Supplemental Excise Tax.
Upon completion of appropriate sections, sign, date
INDIANA DEPARTMENT OF REVENUE
and mail the application and fee(s) if applicable to:
SYSTEM SERVICES
P O BOX 6197
INDIANAPOLIS IN 46206-6197
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