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Click ‘Get Form’ to open it in the editor.
Begin with Line 1A, where you will enter the total number of tires sold during the reporting period. If there are none, simply input '0'.
Proceed to Line 1B for any adjustments. Indicate whether these are positive or negative by using a '+' or '-' sign. Again, enter '0' if no adjustments apply.
In Line 1C, calculate the total tires by adding Line 1A and Line 1B. Enter this total in the field provided.
For batteries, repeat similar steps in Lines 2A, 2B, and 2C for batteries sold and adjustments.
Calculate the total fees due in Line 7 by following the instructions provided for Lines 5 and 6.
Complete any additional fields as necessary, including interest for late payment in Line 9 and approved credits in Line 10.
Finally, review your entries for accuracy before signing and dating the return at the bottom of the form.
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For failure to file a Tire and Lead-Acid Battery Fee Return on or before the due date, enter five percent (5%) of Line 7 for each month late up to a maximum ofRead more
812-228-5068 Healthcare Provider Name: Phone Number
Return to Fax #: 812-228-5068. Healthcare Provider Name: Phone Number: Fax Number: Patient Name: Date of Birth: (MM-DD-YYYY). May Return to work without workRead more
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