Form Rc-1-Ae - Cigarette Revenue Tax Stamp Electronic Funds Transfer Authorization
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1Illinois Department of Revenue
Cigarette Revenue Tax Stamp
RC-1-AE
Electronic Funds Transfer Authorization
Read this information first
Form RC-1-AE must be attached to Form RC-1-A, Cigarette Tax Stamp Order-Invoice. Keep a copy for your records.
Part 1:
Identify your business
Business name: ___________________________________________________ IBT no.:
__ __ __ __ - __ __ __ __
DBA (if applicable): ___________________________________________
License no.: ____ - _____________
Part 2:
Authorization
I hereby authorize the Illinois Department of Revenue to electronically initiate a
funds transfer as payment for purchase of cigarette revenue tax stamps against the
bank account that was designated by the business listed above in the amount of
$___________________________
Amount of funds transfer
________________________________________________________________
Signature of person authorizing the electronic funds transfer
________________________________________________________________
Date: _____/_____/__________
Printed name of person signing above
Month
Day
Y ear
Official use
I
nvoice no. :_________________________
Initiation date:_____/_____/__________
Initiator: ___________________________
This form is authorized as outlined by the Illinois Administrative Code, Title 86, Part 750. Disclosure of this information is required
of those taxpayers to whom this form applies. This form has been approved by the Forms Management Center.
IL-492-4331
RC-1-AE (N-08/02)
Illinois Department of Revenue
Cigarette Revenue Tax Stamp
RC-1-AE
Electronic Funds Transfer Authorization
Read this information first
Form RC-1-AE must be attached to Form RC-1-A, Cigarette Tax Stamp Order-Invoice. Keep a copy for your records.
Part 1:
Identify your business
Business name: ___________________________________________________ IBT no.:
__ __ __ __ - __ __ __ __
DBA (if applicable): ___________________________________________
License no.: ____ - _____________
Part 2:
Authorization
I hereby authorize the Illinois Department of Revenue to electronically initiate a
funds transfer as payment for purchase of cigarette revenue tax stamps against the
bank account that was designated by the business listed above in the amount of
$___________________________
Amount of funds transfer
________________________________________________________________
Signature of person authorizing the electronic funds transfer
________________________________________________________________
Date: _____/_____/__________
Printed name of person signing above
Month
Day
Y ear
Official use
I
nvoice no. :_________________________
Initiation date:_____/_____/__________
Initiator: ___________________________
This form is authorized as outlined by the Illinois Administrative Code, Title 86, Part 750. Disclosure of this information is required
of those taxpayers to whom this form applies. This form has been approved by the Forms Management Center.
IL-492-4331
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