Form Il-1041 - Fiduciary Income And Replacement Tax Return Page 4

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Illinois Department of Revenue
Year ending
____ ____
Schedule D
Benefi ciary Information
Month
Year
Attach to your Form IL-1041
IL Attachment No. 1
Write your name as shown on your Form IL-1041.
Write your
federal employer identifi cation number (FEIN).
___ ___ - ___ ___ ___ ___ ___ ___ ___
_____________________________________________________________
Step 1: Provide the following information
1
1
Write the amount from your
Form IL-1041,
Line
28.
______________________
.
2
2
Write the apportionment factor from your Form IL-1041, Schedule NR, Step 6, Line 3.
____
_________________
Step 2: Identify your benefi ciaries.
Attach additional sheets if necessary.
A
B
C
D
E
F
Total amount of
Check the box if
Pass-through
base income (loss)
the benefi ciary
entity payment
Benefi ciary type
distributable
is an Illinois
amount
Name and Address
SSN or FEIN
(See instructions.)
(See instructions.)
nonresident
(See instructions.)
1
________________________________
________________________________
________________________________
________________________________
______________
______
_________________
_______________
2
________________________________
________________________________
________________________________
________________________________
______________
______
_________________
_______________
3
________________________________
________________________________
________________________________
________________________________
______________
______
________________
_______________
4
________________________________
________________________________
________________________________
________________________________
______________
______
_________________
_______________
5
________________________________
________________________________
________________________________
________________________________
______________
______
_________________
_______________
6
________________________________
________________________________
________________________________
________________________________
______________
______
_________________
_______________
7
Add the amounts shown in Column D for partners or
shareholders for which you have entered a check mark
7
in Column E. Write the total here. (See instructions.)
_________________
*963701110*
IL-1041 Schedule D (R-12/09)
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