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Illinois Department of Revenue
RC-16
Cigarette Tax Claim for Credit
Step 1: Identify the claimant
Do not write above this line.
Name
________________________________________________
Account ID:___ ___ ___ ___ ___ ___ ___ ___
Address ________________________________________________
License no.: ___ - ___ ___ ___ ___ ___
Number and street
Title _____________________________________________
________________________________________________
City
State
ZIP
President, secretary, partner, sole owner, or manager
___________________________ (____)______________
County
Telephone number
Step 2: Describe your claim
1
I am filing this claim for
stamps affixed to unusable packages of cigarettes that I returned to the manufacturer. (Complete Columns A, B, C, and D below.)
unusable stamps that I returned to the Illinois Department of Revenue. (Complete Columns A, B, and D below and enclose the stamps.)
a shortage on a cigarette stamp roll. (Complete Columns A, B, and D below and enclose the remainder of the roll.)
another reason. (Explain the reason and complete Columns A, B, and D below.)
__________________________________________________________________________________________________________
A
B
C
D
Number of cigarettes
Number of stamps
Series and denomination
in each package
Dollar value
__________________________
___________________________
__________________________
__________________________
__________________________
___________________________
__________________________
__________________________
__________________________
___________________________
__________________________
__________________________
__________________________
___________________________
__________________________
__________________________
Total
__________________________
2
Date, as indicated on the bill of lading, that stamps were returned to the manufacturer __ __/__ __/__ __ __ __
3
Stamps returned to _____________________________________________________________________________________________
Name
_____________________________________________________________________________________________
Street address
City
State
ZIP
Step 3: Sign below
Mail your completed claim to:
EXCISE TAXES DIVISION
Under penalties of perjury, I state that I have examined this claim
ILLINOIS DEPARTMENT OF REVENUE
and, to the best of my knowledge, it is true, correct, and complete.
PO BOX 19477
_______________________________________________________
SPRINGFIELD IL 62794-9477
Signature of owner, partner, officer, or authorized agent
Date
If you have questions, call us weekdays between 8 a.m. and 4:30
p.m. at 217 782-6045.
*044701110*
Do not write below this line.
Credit memo no. ____________
Credit amount $_____________
Verified by _______________________________ Date__________
Reviewed by _____________________________ Date__________
Approved by ______________________________ Date__________
This form is authorized as outlined by the Illinois Cigarette Tax Act. 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-492-2704
RC-16 front (R-04/10)
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