Form Idr-85-G - Claim For Credit For Tax Paid

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Illinois Department of Revenue

IDR-85-G

Claim for Credit for Tax Paid

Read this information first

You must complete all steps on this form before we can process your

Mail your completed claim and amended return to:

claim for credit. You must also attach to this form a completed,

MISCELLANEOUS TAXES DIVISION

amended return for each period for which you are claiming a credit.

ILLINOIS DEPARTMENT OF REVENUE

PO BOX 19019

If you have questions, write us at the address at the right or call our

SPRINGFIELD IL 62794-9019

Springfield office weekdays between 8:00 a.m. and 4:30 p.m. at

217 524-6551.

Step 1: Identify your organization

Organization’s name _____________________________________

Date __ __ __ __ __ __ __ __

Month

Day

Year

Address _______________________________________________

License number _________________________________________

Street address

_______________________________________________________

Daytime telephone number _______________________________

City

State

ZIP

_______________________________________________________

Amount of credit claimed

$_______________________________

County

Step 2: Complete the following information

Check the tax for which you are filing this claim. (Check only one box.)

Bingo Tax

Charitable Games Tax

Pull Tabs and Jar Games Tax

Explain all reasons why you are filing this claim. You may use the back of this form if you need additional space.

__________________________________________________________________________________________________________________

Complete the following table.

Amount of tax paid

Subtract Column c

*Date for

(If paid under protest,

from Column b.

which overpayment

write “P” to the left

Tax due

This is the amount

was paid

of the amount.)

as corrected

of credit claimed.

Official use only

___________________

$___________________ $___________________

$___________________ ____________________

___________________

$___________________ $___________________

$___________________ ____________________

___________________

$___________________ $___________________

$___________________ ____________________

___________________

$___________________ $___________________

$___________________ ____________________

Total (Write this amount on Step 1, Line 6.)

$___________________

For Bingo Tax or Pull Tabs and Jar Games Tax claims, write the quarter and year ( e.g., write “02/1998” for the second quarter of 1998).

If you were operating under a limited license for either of these taxes, write the event date ( e.g., “03/02/98 - 03-06/98”).

For Charitable Games Tax claims, write the play date ( e.g., write “04/07/1998” for a play date of April 7, 1998).

Are you a party to any civil suit involving these amounts?

yes

If “yes,” write the name of the suit. ______________________________________________________________________________________

Step 3: Sign below

Under penalties provided by law, including a fine, imprisonment, or both, I state that I have examined this claim and, to the best of my knowledge,

it is true, correct, and complete. I also state that the information is taken from the books and records of the organization for which this claim is filed.

________________________________________________________________________________________________________________

Claimant’s signature

Title ( e.g. , owner, partner, officer, or authorized agent)

Date

Memo no.:

Credit amt.:

This form is authorized as outlined by the Bingo Tax Act, Charitable Games Act, and Pull Tabs and

Verified by:

Date:

Jar Games Tax Act. Disclosure of this information is REQUIRED. Failure to provide information could

Approved by:

Date: