Form Rc-1-A - Cigarette Tax Stamp Order-Invoice
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1Illinois Department of Revenue
RC-1-A
Cigarette Tax Stamp Order-Invoice
Read this information first
Copy distribution
Orders will be filled at your assigned location only:
White
- Initiating office
101 W JEFFERSON ST
- or -
CONCOURSE 300
Canary
- Spfld office
Pink
- Chgo office
PO BOX 19018
100 W. RANDOLPH ST
Goldenrod - Distributor
SPRINGFIELD IL 62794-9018
CHICAGO, IL 60601-3274
Payment must be made by means of Electronic Funds Transfer (EFT).
The Illinois Department of Revenue is not responsible for stamps lost in transit.
If you need assistance, call our Springfield office at 217 785-6613 or 217 524-5409 or our Chicago office at 312 814-3225.
Part 1: Taxpayer information - please print with force
Name:____________________________________________
Illinois business tax number (IBT no.):__ __ __ __-__ __ __ __
Street address:_______________________________________
License number: ___________________________
__________________________________________________
___________________________________ ___/___/______
City
State
ZIP
Date
Authorization (purchasing agent, member of firm, president, treasurer)
Part 2: Stamps - Order by multiplying the number of stamps by the stamp price
10 cigarettes per package - Order hand-applied stamps in sheets (100 stamps per sheet)
1
1 _____________
Number of sheets ______________ X 100 = Number of stamps ______________ X .49
=
20 cigarettes per package - Order machine stamps in rolls (30,000 per roll)
2
2 _____________
Number of rolls ______________ X 30,000 = Number of stamps ______________X .98
=
25 cigarettes per package - Order machine stamps in rolls (4,800 stamps per roll)
3
3 _____________
Number of rolls ______________ X 4,800 = Number of stamps ______________ X 1.225 =
Part 3: Amount Due
4
4 _____________
Add Lines 1 through 3 - Total amount due for stamps.
5
5 _____________
Write the amount of credit you wish to apply.
6
Subtract Line 5 from 4. If this line is a credit balance, do not complete Lines 7 through 11. We will issue
another credit memorandum for the unused credit. Do not deduct the unused balance from future orders until
6 _____________
you receive the new credit memorandum.
7
7 _____________
Total purchases from Line 8 of your last order invoice that represents accumulated stamp purchases from July 1.
8
8 _____________
Add Lines 6 and 7 - Total year-to-date purchase.
If Line 8 is more than $3,000,000 and Line 7 is $3,000,000 or less, go to Line 10. Do not complete Line 9.
Discount
9
9 _____________
If Line 8 is $3,000,000 or less, multiply Line 6 by 1.75 percent (.0175) - Write this amount on Line 10.
If Line 8 is more than $3,000,000, multiply Line 6 by 1.5% (.015) - Write this amount on Line 10.
10
Figure Lines b through Line h for your split discount.
a
a $
3,000,000
Discount base
b
b ____________
Amount from Line 7
c
c ____________
Subtract Line b from Line a
d
d ____________
Multiply Line c by 1.75% (.0175).
e
e ____________
Amount from Line 6
f
f ____________
Amount from Line c
g
g ____________
Subtract Line f from Line e
h
h ____________
Multiply Line g by 1.5% (.015)
10 _____________
Add Lines d and h, and write the total on Line 10.
11
11 _____________
Subtract Line 10 from Line 6 - pay this amount by Electronic Funds Transfer (EFT).
Part 4: Authorization
I hereby authorize the Illinois Department of Revenue to electronically initiate a funds transfer as payment for purchase of cigarette tax stamps
against the bank account that was designated by the business listed above.
______________________________________________________
____________________________________
___/___/______
Signature of person authorizing electronic funds transfer
Printed name of person authorizing the electronic funds transfer
Date
Official Use
Do not write below this line
Filled by:
______
Picked up by:
______ Carrier
______ Agent
Checked by:
______
Shipped by:
______ Express
______ Registered
______ Insured
Posted by:
______
This form is authorized as outlined by the Cigarette and Cigarette Use Tax Acts. Disclosure of this information is REQUIRED. Failure
RC-1-A (R-06/03)
to provide information could result in a penalty. This form has been approved by the Forms Management Center.IL-492-2285
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