Form Rr-374 - Notice Of Payment Under Protest
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Illinois Department of Revenue
Notice of Payment Under Protest
Step 1: Identify yourself (and your business, if applicable)
1
5
_______________________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___ ___
First name
Middle initial
Last name
Social security number
2
6
_______________________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___ ___
Business name
Federal employer identification number
3
7
_______________________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___
Street address
Illinois business tax number
8
_______________________________________________________________________
____________________________________
City
State
ZIP
License number
(
)
—
4
________________________________
Daytime phone number
Step 2: Specify what payment is made under protest and the amount
9
Date ___ ______ ______ ___ ___ ___
10
You will please take notice that $________________________ of the enclosed or attached remittance in the amount of
$________________________ for taxes due for the period of ________________________, penalties thereon, and interest accrued to the
date of this payment is made under protest as specified in the State Officers and Employees Money Disposition Act, 30 ILCS 230/2a and 2a.1.
11
Write the amount of tax, penalty, and interest paid under protest for each applicable tax type.
Column A
Column B
Column C
Column D
Column E
Tax
Penalty
Interest
Total (A+B+C)
Total for tax type
a
Retailers’ Occupation Tax
(1) State portion
______________ ______________ ______________ ______________
(2) Local portion
______________ ______________ ______________ ______________
(3) Mass transit
______________ ______________ ______________ ______________
11a
(4) Other: _____________________ ______________ ______________ ______________ ______________
______________
b
Use Tax
(1) State portion
______________ ______________ ______________ ______________
(2) Local portion
______________ ______________ ______________ ______________
(3) Mass transit
______________ ______________ ______________ ______________
11b
(4) Other: _____________________ ______________ ______________ ______________ ______________
______________
c
Service Occupation Tax/Service Use Tax
(1) State portion
______________ ______________ ______________ ______________
(2) Local portion
______________ ______________ ______________ ______________
(3) Mass transit
______________ ______________ ______________ ______________
11c
(4) Other: _____________________ ______________ ______________ ______________ ______________
______________
d
Other Occupation Taxes or Fees (Identify tax type — e.g. Automobile Renting Occupation Tax, Tire User Fee.)
(1) ___________________________ ______________ ______________ ______________ ______________
(2) ___________________________ ______________ ______________ ______________ ______________
(3) ___________________________ ______________ ______________ ______________ ______________
11d
(4) ___________________________ ______________ ______________ ______________ ______________
______________
e
Income Tax
(1) Individual Income Tax
______________ ______________ ______________ ______________
(2) Business Income Tax
______________ ______________ ______________ ______________
(3) Withholding Income Tax
______________ ______________ ______________ ______________
11e
(4) Other: _____________________ ______________ ______________ ______________ ______________
______________
f
Excise Tax (Identify tax type — e.g., Hotel Operators’ Occupation Tax, Motor Fuel Use Tax.)
(1) ___________________________ ______________ ______________ ______________ ______________
(2) ___________________________ ______________ ______________ ______________ ______________
(3) ___________________________ ______________ ______________ ______________ ______________
11f
(4) ___________________________ ______________ ______________ ______________ ______________
______________
12
12
Add Lines 11a through 11f and write the result. This is the total amount paid under protest.
______________
Step 3: Identify and attach the case or cases for which the payment is made under protest
List the title of the case or cases, the court in which the case or cases are pending, and the general court number assigned to each. If more
than one suit is pending, identify the amount paid under protest for each case. If you are filing at more than one location, list the specific city
or county and the amount of each payment made under protest. Please tell us if a case has not been filed yet.
Step 4: Read the statement and sign below
The undersigned is an original (or intervening) party plaintiff in case or cases identified in the attachment in relation to which the payment
identified above is made under protest.
_______________________________________________________
_______________________________________________________
Signature of person making payment under protest
Authorized officer or agent
This form is authorized as outlined by the Illinois Income Tax Act and the Retailers’ Occupation and related occupation taxes and fees 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-492-2109
RR-374 (R-6/01)
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