Schedule 501b - Terminal Operator'S Schedule Of Disbursements - Indiana Department Of Revenue

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State Form 49091
Schedule 501B
10-03
Terminal Operator's Schedule of Disbursements
Terminal Operator Name
License Number
FEIN
Terminal Code
Month/Year
You may photocopy this blank schedule for future filings. Attach additional sheets if necessary.
Product Code/Type (Check One)
For Use with Reporting Special Fuel
For Use with Reporting Gasoline/Oil Inspection
142
Kerosene
065
Gasoline
161
Low Sulphur Diesel #1 - undyed
124
Gasohol
167
Low Sulphur Diesel #2 - undyed
125
Aviation Gasoline
226
High Sulphur Diesel - dye added
130
Jet Fuel Gasoline
227
Low Sulphur Diesel - dye added
142
Kerosene
231
No. 1 Diesel - dye added
150
#1 Fuel Oil - undyed
284
Biodiesel - undyed
161
Low Sulphur Diesel #1 - undyed
290
Biodiesel - dye added
231
No. 1 Diesel - dye added
OTH
Other
241
Ethanol
243
Methanol
282
#1 High Sulfer Diesel - undyed
OTH
Other
Transporter Information
Position Holder Information
(11)
(12)
Position
Position
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(1)
(10)
Holder's
Holder's
Destination
Document
Document
Net
Name
FEIN
Mode
Name/
FEIN
Gross
Customer
Customer
State
Address
Date
Number
Gallons
Gallons
FEIN
Name
Total

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Parent category: Financial
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