Form Rcoa-18 - Application For Replacement Coin-Operated Amusement Device Decals
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1Illinois Department of Revenue
RCOA-18
Application for Replacement
Coin-Operated Amusement Device Decals
Step 1: Identify your business
1
3
Business name ________________________________
IBT no.
_________________________________
Illinois business tax number
2
4
Mailing address ________________________________
FEIN or SSN _________________________________
Number and street
Federal employer identification number or Social Security number
5
_____________________________________________
Telephone no. (_____)__________________________
City
State
ZIP
Step 2: Identify the decals to be replaced
Check what happened to the original decal. Write the decal number, if known, and the date the decal was issued.
(You can attach additional sheets.)
Original decal was:
Decal number
Date decal was issued
1
1
Stolen
Lost
Misplaced
_______________
__ __/__ __/__ __ __ __
Month
Day
Year
2
2
Stolen
Lost
Misplaced
_______________
__ __/__ __/__ __ __ __
Month
Day
Year
3
3
Stolen
Lost
Misplaced
_______________
__ __/__ __/__ __ __ __
Month
Day
Year
Step 3: Sign here if you are the replacement decal requester
The person in whose name the decals were issued, or an agent authorized in writing for that purpose, must complete and
sign this form. If this form is completed and signed by an officer of a corporation, write the person’s title and affix the
corporate seal.
Affix corporate seal here.
Under penalties of perjury, I certify that the above identified decals issued
by the Illinois Department of Revenue have been stolen, lost, or misplaced.
_______________________________________________
Signature
Title (if corporate officer)
Date
Step 4: Sign here if you are a notary public
Note:
A notary public must sign this application in order for it to be processed.
State of _______________________________________
County of _______________________________________
Affix notary seal here.
Subscribed and sworn to before me this ___________ day
of ______________________________, A.D. __ __ __ __ .
Month
Year
My commission expires __ __/__ __/__ __ __ __.
Mail to: MISCELLANEOUS TAXES DIVISION
Month
Day
Year
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19019
_______________________________________________
SPRINGFIELD IL 62794-9019
Signature
Date
If you have questions, write to us at the address above or
call our Springfield office weekdays between 8:00 a.m.
and 4:30 p.m. at 217 785-5862.
This form is authorized by the Coin-Operated Amusement Device and Redemption Machine Tax Act. Disclosure of this information is REQUIRED. Failure to comply may result in a penalty.
This form has been approved by the Forms Management Center.
IL-492-3340
RCOA-18 (R-5/98)
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