Form Ds-1 Dry-Cleaning Solvent Tax Return
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Illinois Department of Revenue
DS-1
REV 05 Form 160
Dry-Cleaning Solvent Tax Return
E S
___/___/___
NS DP CA RC
Identify your business
Do not write above this line.
Name
______________________________________________
Account ID: ___ ___ ___ ___ ___ ___ ___ ___
License no.: DS - ___ ___ ___ ___ ___
Address ______________________________________________
Number and street
This return is for the quarter ending ___ ___/___ ___ ___ ___
______________________________________________
Month
Year
City
State
ZIP
Step 1: Figure your tax on sales of dry-cleaning solvents
1
Chlorine-based solvents:
a
1a
Total gallons sold.
_______________________
b
1b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
1c
Subtract Line 1b from Line 1a for net gallons sold subject to tax.
_______________________
d
1d
Multiply Line 1c by $10.00 for your tax on chlorine-based solvents.
$______________________
2
Petroleum-based solvents:
a
2a
Total gallons sold.
_______________________
b
2b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
2c
Subtract Line 2b from Line 2a for net gallons sold subject to tax.
_______________________
d
2d
Multiply Line 2c by $2.00 for your tax on petroleum-based solvents.
$______________________
3
Green solvents sold that are not for use in virgin facilities:
a
3a
Total gallons sold.
_______________________
b
3b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
3c
Subtract Line 3b from Line 3a for net gallons sold subject to tax.
_______________________
d
3d
Multiply Line 3c by $1.75 for your tax on these solvents.
$______________________
4
Green solvents sold for use in virgin facilities:
a
4a
Total gallons sold.
_______________________
b
4b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
4c
Subtract Line 4b from Line 4a for net gallons sold subject to tax.
_______________________
d
4d
Multiply Line 4c by $0.35 for your tax on these solvents.
$______________________
Step 2: Figure your tax on purchases of dry-cleaning solvents
5
Total gallons of chlorine-based solvents purchased from an
5
unregistered out-of-state supplier.
_______________________
6
6
Multiply Line 5 by $10.00 for your tax on chlorine-based solvents.
$______________________
7
Total gallons of petroleum-based solvents purchased from an
7
unregistered out-of-state supplier.
_______________________
8
8
Multiply Line 7 by $2.00 for your tax on petroleum-based solvents.
$______________________
9
Total gallons of green solvents purchased from an unregistered
9
out-of-state supplier and which are not for use in a virgin facility.
_______________________
1 0
10
Multiply Line 9 by $1.75 for your tax on these solvents.
$______________________
11
Total gallons of green solvents purchased from an unregistered
11
out-of-state supplier for use in a virgin facility.
_______________________
1 2
12
Multiply Line 11 by $0.35 for your tax on these solvents.
$______________________
Step 3: Figure your amount due
1 3
13
Add Lines 1d, 2d, 3d, 4d, 6, 8, 10, and 12.
$______________________
*216001110*
14
14
Figure your discount. See Step-by-Step instructions.
$______________________
15
15
Subtract Line 14 from Line 13. This is your total tax due.
$______________________
16
16
Credit you wish to apply.
$______________________
17
17
Subtract Line 16 from Line 15. This is your total amount due.
$______________________
Step 4: 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 as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this information is
DS-1 front (R-10/12)
required. Failure to provide information may result in this form not being processed and may result in a penalty.
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