Form Eda-117-B - Multiple Location Schedule For E911 Surcharge

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Illinois Department of Revenue
EDA-117-B
Multiple Location Schedule for E911 Surcharge
(attach to EDA-98)
Account ID: ____ ____ ____ ____ - ____ ____ ____ ____
Audit period you are fi ling the claim on:
___ ___/___ ___/___ ___ ___ ___ through ___ ___/___ ___/___ ___ ___ ___
Month
Day
Year
Month
Day
Year
Chicago locations
E911 Surcharge
non-Chicago locations
E911 Surcharge
Completed by________________________________________________ Date_____/_____/_____
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is fi led. Disclosure of this information is
required. Failure to provide information may result in this form not being processed and may result in a penalty.
EDA-117-B (N-09/11)
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