Form Ds-1 Dry-Cleaning Solvent Tax Return Illinois
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Illinois Department of Revenue
DS-1
FORM 160 REV 03
Dry-Cleaning Solvent Tax Return
E S ___/___/___
NS DP CA RC
Step 1: Identify your business
Do not write above this line.
1
3
Name ______________________________________________
IBT no. ___ ___ ___ ___ - ___ ___ ___ ___
Illinois business tax number
2
4
Address ____________________________________________
This return is for the quarter ending ___ ___/___ ___ ___ ___
Number and street
Month
Year
___________________________________________________
City
State
ZIP
Step 2: Figure your tax on sales of dry-cleaning solvents
5
Chlorine-based solvents:
a
5a
Total gallons sold.
_______________________
b
5b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
5c
Subtract Line 5b from Line 5a.
_______________________
d
5d
Multiply Line 5c by $10.00 for your tax on chlorine-based solvents.
$______________________
6
Petroleum-based solvents:
a
6a
Total gallons sold.
_______________________
b
6b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
6c
Subtract Line 6b from Line 6a.
_______________________
d
6d
Multiply Line 6c by $2.00 for your tax on petroleum-based solvents.
$______________________
7
Green solvents sold that are not for use in virgin facilities:
a
7a
Total gallons sold.
_______________________
b
7b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
7c
Subtract Line 7b from Line 7a for net gallons sold subject to tax.
_______________________
d
7d
Multiply Line 7c by $1.75 for your tax on these solvents.
$______________________
8
Green solvents sold for use in virgin facilities:
a
8a
Total gallons sold.
_______________________
b
8b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
8c
Subtract Line 8b from Line 8a for net gallons subject to tax.
_______________________
d
8d
Multiply Line 8c by $0.35 for your tax on these solvents.
$______________________
Step 3: Figure your tax on purchases of dry-cleaning solvents
9
Total gallons of chlorine-based solvents purchased from an
9
unregistered out-of-state supplier.
_______________________
1 0
10
Multiply Line 9 by $10.00 for your tax on chlorine-based solvents.
$______________________
11
Total gallons of petroleum-based solvents purchased from an
11
unregistered out-of-state supplier.
_______________________
1 2
12
Multiply Line 11 by $2.00 for your tax on petroleum-based solvents.
$______________________
13
Total gallons of green solvents purchased from an unregistered
13
out-of-state supplier and which are not for use in a virgin facility.
_______________________
1 4
14
Multiply Line 13 by $1.75 for your tax on these solvents.
$______________________
15
Total gallons of green solvents purchased from an unresgistered
15
out-of-state supplier for use in a virgin facility.
_______________________
1 6
16
Multiply Line 15 by $0.35 for your tax on these solvents.
$______________________
Step 4: Figure your amount due
1 7
17
Add Lines 5d, 6d, 7d, 8d, 10, 12, 14, and 16.
$______________________
18
18
Figure your discount. See Step-by-Step instructions.
$______________________
19
Subtract Line 18 from Line 17. This is your total payment due. Make your check payable to
19
“Illinois Department of Revenue.”
$______________________
Step 5: Sign below
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
______________________________________________________
Taxpayer’s signature
Telephone
Date
Tax preparer’s signature
Telephone
Date
Mail Form x and payment to: Dry-Cleaning Solvent Tax, Illinois Department of Revenue, PO BOX 19034, Springfield IL 62794-9034
This form is authorized by the Dry Cleaner Environmental Response Trust Fund Act. Disclosure of this information is REQUIRED. Failure to provide
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-3783
DS-1 front (R-12/09)
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