Form ST-115                                            Indiana Department of Revenue                                                             Check Type of Return 
        State Form 321                                                                                                                                      Annual      
        (R7 / 4-19)                                                                                                                                         Quarterly
                                                            Consumer’s Use Tax Return
                             Period beginning (month/year)                                                and ending (month/year)                           Monthly
Name                                                                                                                            Tax Computation
                                                                                                             Total purchases subject to tax
Street Address                                                                                            1.
                                                                                                             (from reverse side)..................  $ s, s, .
City or Post Office, County, State, and Zip Code                                                          2. Use Tax
                                                                                                             (7% of Line 1)........................   s, s, .
Principal Business Activity                                 Social Security Number                        3. Penalty (10% of Line 2) &
                                                                                                             Interest (call the Department*) 
ID Type            Indiana TID #                            ID Number                                        if paid after due date...............    s, s, .
(circle one)                                   Federal ID #                                               4. Total amount due
                                                                                                             (add Lines 2 and 3 )................   $ s, s, .
                                                                                                          For Departmental Use Only
 Signature & Title if other than individual return                    Date
I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, cor-
rect, and complete return.                                                                                *Call  (317) 233-4015 or by e-mail at: www.in.gov/dor/contact/email.html

        List all purchases of tangible personal property subject to use tax.
Name and Address of Seller Description of Property Purchased             Date of       Purchase Price
                                                                         Purchase      of Property

                                                                                  $ s,        s,            .

                                                                                    s,        s,            .

                                                                                    s,        s,            .

                                                                                    s,        s,            .

                                                                                    s,        s,            .

                                                                                    s,        s,            .
        (if more space is needed, please attach a schedule)
                                                                         TOTAL*   $ s,        s,            .
        After completing this form, mail with payment to:                           *This amount goes on Line 1,
Indiana Department of Revenue, P.O. Box 7228, Indianapolis, IN 46207-7228              on the front of this form.