Form Ds-1 - Dry-Cleaning Solvent Tax Return
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Illinois Department of Revenue
DS-1
FORM 160
REV 04
Dry-Cleaning Solvent Tax Return
E S
___/___/___
NS DP CA RC
Step 1: Identify your business
Do not write above this line.
1
3
Name ______________________________________________
Account ID:___ ___ ___ ___ ___ ___ ___ ___
4
License no.: DS - ___ ___ ___ ___ ___
2
Address ____________________________________________
Number and street
5
This return is for the quarter ending ___ ___/___ ___ ___ ___
___________________________________________________
Month
Year
City
State
ZIP
Step 2: Figure your tax on sales of dry-cleaning solvents
6
Chlorine-based solvents:
a
6a
Total gallons sold.
_______________________
b
6b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
6c
Subtract Line 6b from Line 6a.
_______________________
d
6d
Multiply Line 6c by $10.00 for your tax on chlorine-based solvents.
$______________________
7
Petroleum-based solvents:
a
7a
Total gallons sold.
_______________________
b
7b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
7c
Subtract Line 7b from Line 7a.
_______________________
d
7d
Multiply Line 7c by $2.00 for your tax on petroleum-based solvents.
$______________________
8
Green solvents sold that are not for use in virgin facilities:
a
8a
Total gallons sold.
_______________________
b
8b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
8c
Subtract Line 8b from Line 8a for net gallons sold subject to tax.
_______________________
d
8d
Multiply Line 8c by $1.75 for your tax on these solvents.
$______________________
9
Green solvents sold for use in virgin facilities:
a
9a
Total gallons sold.
_______________________
b
9b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
9c
Subtract Line 9b from Line 9a for net gallons subject to tax.
_______________________
d
9d
Multiply Line 9c by $0.35 for your tax on these solvents.
$______________________
Step 3: Figure your tax on purchases of dry-cleaning solvents
1 0
Total gallons of chlorine-based solvents purchased from an
10
unregistered out-of-state supplier.
_______________________
1 1
11
Multiply Line 10 by $10.00 for your tax on chlorine-based solvents.
$______________________
12
Total gallons of petroleum-based solvents purchased from an
12
unregistered out-of-state supplier.
_______________________
1 3
13
Multiply Line 12 by $2.00 for your tax on petroleum-based solvents.
$______________________
14
Total gallons of green solvents purchased from an unregistered
14
out-of-state supplier and which are not for use in a virgin facility.
_______________________
1 5
15
Multiply Line 14 by $1.75 for your tax on these solvents.
$______________________
16
Total gallons of green solvents purchased from an unregistered
16
out-of-state supplier for use in a virgin facility.
_______________________
1 7
17
Multiply Line 16 by $0.35 for your tax on these solvents.
$______________________
Step 4: Figure your amount due
1 8
18
Add Lines 6d, 7d, 8d, 9d, 11, 13, 15, and 17.
$______________________
*016021110*
19
19
Figure your discount. See Step-by-Step instructions.
$______________________
20
20
Subtract Line 19 from Line 18. This is your total tax due.
$______________________
21
21
Credit you wish to apply.
$______________________
22
22
Subtract Line 21 from Line 20. This is your total amount due.
$______________________
Step 5: Sign below
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
______________________________________________________
Taxpayer’s signature
Telephone
Date
Tax preparer’s signature
Telephone
Date
Mail Form DS-1 and payment to: Dry-Cleaning Solvent Tax, Illinois Department of Revenue, PO BOX 19019, Springfield IL 62794-9019
This form is authorized by the Dry Cleaner Environmental Response Trust Fund Act. Disclosure of this information is REQUIRED. Failure to provide
DS-1 front (R-04/10)
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-3783
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