Form Ets-33 Application For Duplicate Credit Memorandum - 1996
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Illinois Department of Revenue
ETS-33
Application for
Duplicate Credit Memorandum
Section 1: For official use only
Name
_________________________________________________________________________________________
Address
_________________________________________________________________________________________
City, state, ZIP _________________________________________________________________________________________
Original credit memo:
Reissued credit memo:
License number
_______________________
IL business tax (IBT) number
__ __ __ __ - __ __ __ __
Original credit memo number
_______________________
Reissued credit memo number
_______________________
Date on original credit memo
__ __ / __ __ / __ __ __ __
Date on reissued credit memo
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
Original credit memo amount
$_______________________
Reissued credit memo amount $_______________________
Do not write above this line.
Section 2: Identify the requestor
Name of person or firm making this request __________________________________________________________________
Please print
Title (if corporation) _____________________________________________________________________________________
I state that the original credit memorandum shown above and issued by the Illinois Department of Revenue has been
misplaced, lost, or destroyed, thereby preventing the use of all or part of the amount to pay any current or future taxes due the
department.
Signature ________________________________________________________________
Date______________________
Section 3: Mail the form
Mail this completed form to:
MISCELLANEOUS TAXES DIVISION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19477
SPRINGFIELD IL 62794-9477
If you have any questions, please call our Springfield office weekdays between 8 a.m. and 4:30 p.m. at 217 785-5851.
This form is authorized as outlined by the Retailers’ Occupation Tax Act and related acts. Disclosure of this information is REQUIRED.
SOY-BASE INK
ETS-33 (R-5/96)
Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-3264
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