Indiana > Statewide > Department Of Revenue > Motor Carrier
Annual Report Form MCS-3 - Indiana
| Annual Report Form Form. This is a Indiana form and can be used in Motor Carrier Department Of Revenue Statewide . |
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MCS-3 State Form 48761 (R2 / 10-12) Indiana Department of Revenue Motor Carrier Services Annual Report Form For the Year Ending December 31, ______ Due April 30th ** NOTICE ** On or before April 30th of each year, every motor carrier, who operated intrastate motor vehicles for-hire for household goods and/or passengers, over the public highways of the State of Indiana, under a certificate or permit of public convenience and necessity issued by the Department, shall file with the Department an Annual Report for the preceding calendar year. You may fax your completed form to (317) 615-7374 or mail to Indiana Department of Revenue, Motor Carrier Services Division, 7811 Milhouse Road, Suite M, Indianapolis, IN 46241-9612. Section A: Motor Carrier Information Legal Name: ____________________________________________________________________________________ Doing Business As (DBA) Name: ____________________________________________________________________ Physical Address: ________________________________________________________________________________ City: __________________________________ State: ___________________ Zip Code: _____________________ Mailing Address: _________________________________________________________________________________ City: __________________________________ State: ___________________ Zip Code: _____________________ Contact Person\Title: __________________________________ Telephone Number: ___________________________ Email Address:_______________________________________ IMCA# /IN ID#: ______________________________________ US DOT Number: ____________________________ FEIN: ______________________________________________ SSN: ______________________________________ Medical Provider Number: ______________________________ Section B: Kind of Organization (check one) A. ___ Individual B. ___ Partnership C. ____Corporation D. ___ Other: ________________________________ Section C: Type of Motor Carrier (check all that apply) 1. ___ Common Carrier 2. ___ Contract Carrier 3. ___ Passenger Carrier 4. ___ Household Goods Carrier Section D: Partnership (complete only if Section B Line B is checked) Partner's Name 1. 2. 3. _________________________________________ _________________________________________ _________________________________________ Address ______________________________________________ ______________________________________________ ______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Section E: Corporation (complete only if Section B Line C is checked) (A) Directors 1. 2. 3. 4. _________________________________________ _________________________________________ _________________________________________ _________________________________________ Address ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Address ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ (B) Principal General Officers 1. 2. 3. 4. _________________________________________ _________________________________________ _________________________________________ _________________________________________ (C) Principal Stockholders Name 1. 2. 3. 4. ____________________________ ____________________________ ____________________________ ____________________________ Address ___________________________________ ___________________________________ ___________________________________ ___________________________________ Number of Shares ____________________ ____________________ ____________________ ____________________ Section F: Revenue Equipment (The information below must be given for equipment in service at the end of the year.) Trucks Total Vehicles Owned Total Vehicles Leased Total Number of Vehicles Section G: Annual Mileage Transportation of Household Goods Total Intrastate Mileage Transportation of Medicaid Passengers Transportation of Passengers Truck Tractors Semitrailers Buses Vans Limousines Other Total American LegalNet, Inc. www.FormsWorkFlow.com Income Statement Operating Revenues: 1. 2. 3. 4. 5. Household Goods Revenue Passenger Revenue Other Operating Revenue Rents Received Total Operating Revenue (Add lines 1 through 4) $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ Operating Expenses: 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Repair & Servicing of Equipment Tires & Tubes Drivers' & Helpers' Wages Gasoline & Oil Other Transportation Expenses Station & Terminal Expenses Advertising & Traffic Expenses Insurance Office Salaries & Expenses Taxes & Licenses Rent Paid Depreciation Total Operating Expenses (Add Lines 6 through line 17) Net Operating Revenue (Subtract line 18 from line 5) $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ Other Income and Expenses: 20. 21. Miscellaneous Income Non-operating Expenses $ ____________________ $ ____________________ $ ____________________ Net Income (Add line 19 and line 20 then subtract line 21) American LegalNet, Inc. www.FormsWorkFlow.com Balance Sheet Assets 1. 2. 3. 4. 5. 6. 7. 8. 9. Cash Notes Receivable & Investments Accounts Receivable Prepayments Materials & Supplies Plant & Equipment Less: Allowance for Depreciation Organization, Certificates, Permits Total Assets (Add lines 1 through 8) $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ Liabilities and Equity 10. 11. 12. 13. 14. 15. 16. 17. 18. Notes & Mortgages Payable Accounts Payable Salaries & Wages Payable Accrued Taxes & Other Expenses Capital Stock Sole Proprietorship Partnership Surplus of Deficit Total Liabilities (Add lines 10 through 17) $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ American LegalNet, Inc. www.Forms
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