Form ST-115                                                              Indiana	Department	of	Revenue                                            Check Type of Return	
        State	Form	321                                                                                                                                          Annual							
        (R5/	3-08)
                                                            Consumer’s Use Tax Return                                                                           Quarterly
	       	                  		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, 100 N. Senate Ave, Indianapolis, IN 46204               on the front of this form.