Form FT-ES                                Indiana Department of Revenue
State Form 49410
(R15 / 8-19)                 Indiana Financial Institution Tax Return
                                        Estimated Quarterly Payment
                            Due the 20th day of the 4th, 6th, 9th, and 12th months of the tax year.

Name          ________________________________________________                                     (Do Not Write Above)

Address       ________________________________________________

              ________________________________________________

 Federal Employer Identification Number                         _______________________     _________________
                                                                Signature of Officer               Title

 Voucher Number        Calendar or Fiscal Due Date              __________________   _______________________
 (Enter 1, 2, 3, or 4)      Year Ending   (Enter MM-DD-YYYY)    Date                               Daytime Telephone Number
                       (Enter MM-YYYY)
                                                                Financial Institution Tax Due for the Quarter

                                                                Enter Total Tax Here:  

                                                                Pay this amount, with U. S. funds. Do not send cash.
Indiana Department of Revenue
P.O. Box 7228                                                   Make check payable to Indiana Department of 
Indianapolis, IN 46207-7228                                     Revenue.

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                             Instructions for Completing Form FT-ES

Quarterly payments of estimated financial institution tax for cal-  Use the preprinted Form FT-QP estimated payment vouchers 
endar-year taxpayers are due on April 20, June 20, Sept. 20, and    mailed to you at the beginning of your tax year. If you make 
Dec. 20 of the taxable year. Fiscal-year and short tax-year filers  payment by EFT, you don’t need to file FT-QP forms. If you do 
must remit by the 20th day of the fourth, sixth, ninth, and 12th    not have preprinted forms and need coupon vouchers, fill out the 
months of their tax periods.                                        appropriate FT-ES voucher for the tax period. Enter the total finan-
                                                                    cial institution tax due for the quarter.
Form FT-QP must be used when making these quarterly pay-
ments. (Do not use Form IT-6.) Please note the voucher number       Any penalty and interest paid as a result of a late payment as-
on the form when making the payment for that quarter. Payments      sessment cannot be claimed as a credit on the annual return.
made after the quarterly due date will be reported in the following 
quarter when paid.                                                  Claims for refunds are processed on an annual basis only. If 
                                                                    errors are discovered on a quarterly filing, these errors should be 
If the annual tax liability is less than $2,500, estimated payments adjusted on either the next quarterly return or the annual return. 
are not required to be made. If the quarterly payment exceeds       Adjustments of quarterly returns must be made during the taxable 
$5,000, payments must be made by electronic funds transfer          year of such quarterly returns, and a complete explanation should 
(EFT). Contact the EFT Section at (317) 232-5500 for more infor-    accompany that return.
mation.
                                                                    Each return must be signed by an authorized officer.

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