Form Rpu-5 - Self-Assessing Purchaser Worksheet - Illinois Page 2

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Step 2: Identify your delivering suppliers and accounts (continued)
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
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
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
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
This form is authorized by the Electricity Excise Tax Law. Disclosure of this information is REQUIRED. Failure to provide
RPU-5 back (R-6/98)
information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-3832
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