Form Rcoa-1 - Coin-Operated Amusement Device Tax Decal Order Form - 2010
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Illinois Department of Revenue
RCOA-1
Coin-Operated Amusement Device Tax Decal Order Form
Read this information first
Station no. 607
There is an annual tax of $30 imposed for the operation of each coin-operated amusement device (COAD) and redemption machine. You
must annually order tax decals on or before July 31st by completing Form RCOA-1 and Form RCOA-1-A, Coin-Operated Amusement Device
Schedule. You must make payment in full to receive your tax decals.
Note:
If you operate/display COAD and redemption machines without tax decals you will be subject to a penalty and the machines may be seized.
Step 1: Identify your business
1
4
Name:
_____________________________________________
Account ID: __ __ __ __ __ __ __ __
2
5
Address:
___________________________________________
FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
Number and street
Federal Employer Identification number
6
__________________________________________________
Social Security number (if no FEIN):__ __ __ - __ __ - __ __ __ __
City
State
ZIP
3
❐
7
Check here if your address has changed.
License number: AD - __ __ __ __ __
Step 2: Tell us the number of tax decals you are ordering
8
8a
Write the number of tax decals you need to order on the line
_____ jukeboxes
8b
next to the type of machine for which you are ordering tax decals.
_____ mechanical rides
Note:
8c
You must also complete and attach Form RCOA-1-A to
_____ pinballs
8d
identify each machine for which you are ordering a tax decal.
_____ pool games
8e
_____ redemption machines
8f
_____ shuffleboards
8g
_____ video games - amusement
(e.g., Pac Man, Golf)
8h
_____ video games - simulated gaming
(e.g., poker, blackjack)
8i
_____ other (brief description)
____________________________________________
9
9
Add Line 8a through 8i. This is the total number of tax decals you need to order (Step 4, Line 11).
___________________________
Step 3: Tell us the tax year for which you are ordering tax decals
10
August 1, 20__ __ to July 31, 20 __ __
Year
Year
Step 4: Figure your tax
11
11
Number of tax decals you need to order (the total number from Step 2, Line 9).
___________________________
12
12
Multiply Line 11 by $30.
$_________________________
13
13
Penalty (if applicable). See instructions.
$_________________________
14
14
Add Lines 12 and 13. This amount is your total tax and penalty.
$_________________________
15
15
Write the amount of credit you wish to apply.
$_________________________
16
16
Subtract Line 15 from Line 14. This is the total amount due.
$_________________________
Make your check payable to “Illinois Department of Revenue (COAD).”
Step 5: Sign below
Under penalties of perjury, I state that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
(_____)_____ - _____________
__ __/__ __/__ __ __ __
Signature
Daytime telephone
Date
Step 6: Mail your order form or WebFile at tax.illinois.gov.
Mail your completed Form RCOA-1, Form RCOA-1-A, and payment to us at
EXCISE TAXES DIVISION
*048401110*
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19019
SPRINGFIELD IL 62794-9019
Do not write below this line.
License no. ________________
Date issued
/
/
Clerk ID ___________________
__ __
__ __
__ __ __ __
This form is authorized as outlined by the Coin-Operated Amusement Device and Redemption Machine Tax Act. Disclosure of this information is RE-
RCOA-1 (R-04/10)
QUIRED. Failure to provide information could result in penalties. This form has been approved by the Forms Management Center. IL-492-0021
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