Form Pt-11 - Limited Pull Tab And Jar Game Tax Return - 2001
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Illinois Department of Revenue
PT-11
Limited Pull Tab and
Jar Game Tax Return
Station 994*
Step 1: Tell us about your organization and account activity
1
Pull tabs license no. PL-___________________________
When did you sell pull tabs?
From _ _ _ _ _ _ _ _ to _ _ _ _ _ _ _ _
Month Day
Year
Month Day
Year
___________________________________________________________
Organization’s name
2
Is this an amended return?
___________________________________________________________
yes ____ no ____
*Station 995
C/O
3
___________________________________________________________
Has your address changed since your last
Number and street
filing? yes ____ no ____
___________________________________________________________
City, state, ZIP
4
Did you sell any pull tabs this quarter?
yes ____ no ____
If “no,” go to Step 4.
If “yes,” go to Step 2 on the back of
this form.
Step 2: Figure your gross proceeds
(Step 2 is on the back of this form.)
Step 3: Figure your tax
(You must complete Step 2 on the back of this form before you complete Step 3.)
1
1
Gross proceeds. Write the total of Step 2, Column J.
_______________________________
2
2
Total tax due. Multiply Line 1 by 5% (.05), and write the result here.
_______________________________
3
Write the number and amount of each credit memorandum you want
to apply against tax due. You must attach your original memorandum.
Credit number
Credit amount
a _______________________
______________________
b _______________________
______________________
c _______________________
______________________
3
Add Lines a, b, and c and write the result on Line 3.
_______________________________
4
4
Total due. Subtract Line 3 from Line 2, and write the total here.
_______________________________
Make your check payable to “Illinois Department of Revenue.” (Pay this amount.)
Step 4: Sign below
(You must sign and date your return.)
Under penalties of perjury, I state that I have examined this return and that it is true, correct, and complete, and that the total value of the
prizes or merchandise awarded on any day was not greater than $5,000.
__________________________________________________
(____)___________________
_______________________
Taxpayer or authorized officer’s signature
Daytime telephone number
Date
__________________________________________________
(____)___________________
_______________________
Paid tax preparer’s signature
Daytime telephone number
Date
Note: If you fail to sign your return, it will be deemed as not filed and you may be subject to penalties as provided by law.
Mail your completed return and payment to:
PULL TAB TAX
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19019
SPRINGFIELD IL 62794-9019
This form is authorized by the Illinois Pull Tabs and Jar Games Act. Disclosure of this information is required. Failure to
PT-11 front (R-5/01)
comply may result in a penalty. This form has been approved by the Forms Management Center.
IL-492-2092
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