Form Rg-12 - Gas Revenue And Gas Use Tax Affidavit
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Illinois Department of Revenue
RG-12
Gas Revenue and Gas Use Tax Affidavit
Step 1: Read this information first
A delivering supplier must be able to distinguish whether a customer is responsible for Gas Use Tax (based on gas purchased out-
side of Illinois) or Gas Revenue Tax. If you purchase natural gas from an Illinois broker or marketer and pay tax on the purchase,
you must provide a completed Form RG-12 to your delivering supplier to prevent your delivering supplier from charging you Gas
Use Tax. Your delivering supplier will continue to bill you for the Gas Revenue Tax on your transaction charges (e.g., transportation,
delivering, etc.). Keep a copy of your completed Form RG-12 for your records.
If later, any information you provide below should change, you must complete a new Form RG-12. If no changes are needed, you
should submit a new Form RG-12 every five years to keep records current. If you have any questions, call us weekdays between
8:00 a.m. and 4:30 p.m. at 217 782-6045.
Part 2: Your information
1
3
Name: ______________________________________________
License no.: G - ___ ___ ___ ___ ___
2
4
Address: ____________________________________________
Account no.: _________________________________________
Number and street
___________________________________________________
City
State
ZIP
Part 3: Broker or marketer information
5
7
Name: ______________________________________________
I certify that I am an Illinois registered broker or marketer of natural
Name of your broker or marketer
gas. I further state that I collect Gas Revenue Tax from the
customer identified in Part 2.
6
Account no. for the customer identified above:
_____________________________________
___/___/______
_____________________________________
Broker or marketer’s signature
Date
Step 4: Delivering supplier information
8
9
Name: ______________________________________________
Account number for the customer identified in Part 2.
Name of your delivering supplier
_____________________________________
Step 5: Certification
Under penalties of perjury, I state that I have examined this certification and, to the best of my knowledge, it is true, correct, and complete.
____________________________________________________
____/____/________
Customer’s or person responsible for paying taxes signature
Date
Reset
Print
RG-12 (R-04/10)
This form is authorized by the Gas Revenue and Gas Use Tax Acts. 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-492-4356
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