Form Ds-7 - Schedule A - Dry-Cleaning Solvents Sold

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Illinois Department of Revenue
Page _____ of _____
DS-7
Schedule A
Dry-Cleaning Solvents Sold
Read this information first
After you have completed this schedule, make a photocopy and retain the copy for your records; and
Attach the completed original schedule to Form DS-1, Dry-Cleaning Solvent Tax Return.
For additional instructions, see the back of Form DS-1.
Step 1: Identify your business
Name: ____________________________________________
Illinois Business Tax number (IBT no.):__ __ __ __ __ __ __ __
Address: __________________________________________
Dry cleaner license no.:_______________________________
Number and street
License number issued by the Illinois Dry Cleaning Council
_________________________________________________
This schedule is for the quarter ending: __ __ __ __ __
City
State
ZIP
Month
Year
Step 2: Describe your sales of dry-cleaning solvent
Use these abbreviations in Column B: C = Chlorine-based solvent, P = Petroleum-based solvent, G = Green solvent not used in a
virgin facility, V = Green solvent used in a virgin facility. List one type of solvent per purchaser per line.
Column A
Column B
Column C
Identify purchaser
Type of solvent sold
Number of
gallons sold
(Write license no., name, and address)
(write C, P , G, or V)
1
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
2
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
3
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
4
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
5
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
6
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
7
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
8
_______________________________________________
____________________
__________________
_______________________________________________
_______________________________________________
9
9
Add the gallons in Column C , Lines 1 through 8, and write the result.
__________________
10
10
If you are filing more than one Schedule A, write the total of Line 9 from each page.
__________________
This form is authorized by the Dry Cleaner Environmental Response Trust Fund Act. Disclosure of this information is REQUIRED. Failure to
DS-7 front (N-12/03)
provide information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-4260
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