Form Rpu-5 - Self-Assessing Purchaser Worksheet - Illinois
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Illinois Department of Revenue
RPU-5
Self-assessing Purchaser Worksheet
Do not write above this line.
Read this information first
changes, and mail your new worksheet to the address in
If you purchase electricity for nonresidential use and choose
to register and pay the Electricity Excise Tax directly to the
Step 3.
Illinois Department of Revenue, you must complete this
A photocopy of this form will be sent to each delivering
worksheet and attach it to Form RPU-3, Utility Tax Application
supplier listed below. You must complete separate forms for
for Registration.
each delivering supplier if you do not want all of your account
information disclosed to each supplier.
If, at a later date, you need to change any information con-
tained in this worksheet ( e.g., add or delete an account in
If you have any questions, call our Springfield office weekdays
Step 2), you must complete a new worksheet, indicate all
between 8:00 a.m. and 4:30 p.m. at 217 524-5406 or 217 785-
6602.
Step 1: Identify your business
1
4
IBT no. ___ ___ ___ ___ - ___ ___ ___ ___
Business name ______________________________________
Illinois business tax number
2
5
FEIN
___ ___ - ___ ___ ___ ___ ___ ___ ___
Address
Federal employer identification number
___________________________________________________
Number and street
3
Electricity Excise Tax certificate of registration number, if known.
E
___ -___ ___ ___ ___
___________________________________________________
City
State
ZIP
Step 2: Identify your delivering suppliers and accounts
6 List the name and address of each of your delivering suppliers. Next to each delivering supplier, list the account numbers for
which you choose to pay the Electricity Excise Tax directly to us. Additional space is provided on the back of this worksheet.
Delivering supplier
Account numbers
Account numbers
____________________________________________________
__________________________
__________________________
Name
__________________________
__________________________
____________________________________________________
__________________________
__________________________
Number and street
__________________________
__________________________
___________________________________________________
__________________________
__________________________
City
State
ZIP
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Delivering supplier
Account numbers
Account numbers
____________________________________________________
__________________________
__________________________
Name
__________________________
__________________________
____________________________________________________
__________________________
__________________________
Number and street
__________________________
__________________________
___________________________________________________
__________________________
__________________________
City
State
ZIP
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Step 3: Sign below
Under penalties of perjury, I state that I have examined this worksheet and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
______________________________________________________
Signature of owner, partner, or officer
Date
Typed or printed name of person signing to the left
Mail to: Registration and Returns Processing, Illinois Department of Revenue, P.O. Box 19019, Springfield, IL 62794-9019
RPU-5 front (R-6/98)
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