Form Rcoa-19 - Coin-Operated Amusement Device Tax Decal Claim For Credit
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Illinois Department of Revenue
RCOA-19
Coin-Operated Amusement Device Tax Decal
Claim for Credit
Step 1: Identify your business
1
Name: ________________________________________
4 IBT no.: ___ ___ ___ ___ - ___ ___ ___ ___
2
Mailing address: ________________________________
5 FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
______________________________________________
6 SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
3 Phone no.:(___ ___ ___)___ ___ ___ - ___ ___ ___ ___
Step 2: Check the reason you are filing this claim
❒
7
Receive credit for decals I want to transfer. Number of decals:_______
7a Multiply the number of decals by $30. Write that amount here and in Step 3, Line 16.
7a $_______________
7b Serial numbers: __________
__________ __________ __________ __________ __________ __________
__________
__________ __________ __________ __________ __________ __________
❒
8
Overpaid when ordering decals (Form RCOA-1).
❒
9
Duplicate order.
❒
10
Other. Provide a detailed explanation of your claim. Attach additional sheets if needed.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Step 3: Complete the following information
2 0
2 0
11
Year of the tax decal for which you are filing this claim: August 1,
___ ___ to July 31,
___ ___
Note: If you completed Step 2, Line 7a, skip to Line 16 (total from Line 7a).
Column A
Column B
As Originally Filed
Corrected Amounts
12
Number of tax decals you purchased.
12________________
12 ________________
13
Amount of tax you paid.
13________________
13 ________________
14
Amount of penalty you paid
14________________
14 ________________
15
Total amount. Add Lines 13 and 14.
15________________
15 ________________
16
Subtract Column B, Line 15 from Column A, Line 15. This is the amount of your credit.
16 ________________
Step 4: Sign here
- A claim will not be processed without a signature.
Under penalties of perjury, I state that I have examined this claim and that it is true, correct, and complete.
__________________________________________________
Official Use
Signature
Date
No
____________
Mail to:
Amt
____________
ILLINOIS DEPARTMENT OF REVENUE (COAD)
Apv
____________
PO BOX 19477
Vrf
____________
SPRINGFIELD IL 62794-9477
DR
____________
Int D
____________
For questions, call 217 782-6045.
This form is authorized by the Coin-Operated Amusement Device and Redemption Machine Tax Act. Disclosure of this information is REQUIRED. Failure to comply
RCOA-19 ((R-07/07)
may result in a penalty. This form has been approved by the Forms Management Center.
IL-492-3341
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