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Illinois Department of Revenue
ST-16-X
Amended Annual Report of
03
163
REV
FORM
Manufacturer’s Purchase Credit Earned
E S _____/_____/_____
See instructions on the back.
NS CA
Step 1:
Identify your business
1
4
Business name
_____________________________________
Illinois account ID number
___ ___ ___ ___ - ___ ___ ___ ___
2
5
Business address _____________________________________
Write the purchase year that you are amending
___ ___ ___ ___
Year
Street address
6
____________________________________________________
If you are a graphic artist, check this box.
City
State
ZIP
3
( ______ ) _______________________
Business phone number
Step 2:
Identify purchases that were exempt
(Do not round your fi gures.)
This report will replace your original fi ling. For each line below, report all fi gures as they should have been fi led.
If you do not complete all of the following information, we will reduce or deny your credit.
A
B
C
Month of exempt
Purchase price
Tax that would
Amount of
purchase
of exempt items
State tax rate
have been due
Percentage
credit earned
1
January
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
2
February
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
3
March
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
4
April
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
5
May
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
6
June
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
7
July
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
8
August
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
9
September
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
10
October
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
11
November
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
12
December
$ ___________________ X
.0625
= $ ___________________ X
.50
= $ __________________
Total
$
Total
$
___________________
__________________
(Column A)
(Column C)
Step 3:
Sign below
Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete.
__ __ /__ __ / __ __ __ __
______________________________________________________________(____)________________
Taxpayer’s signature
Daytime phone number
Date
__ __ /__ __ / __ __ __ __
______________________________________________________________(____)________________
Preparer’s signature
Preparer’s name (Please print.)
Daytime phone number
Date
This form is authorized by the Illinois Retailers’ Occupation Tax Act and related tax acts. Disclosure of this information is REQUIRED. Failure
to provide this information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-3588
ST-16-X front (R-12/10)
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