Form Rc-1-A - Cigarette Tax Stamp Order-Invoice
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1
2Illinois Department of Revenue
RC-1-A
Cigarette Tax Stamp Order-Invoice
Station nos.: 915 and 918
Read this information first
• Orders will be filled at your assigned location only:
101 W JEFFERSON ST
- or -
CONCOURSE 300
PO BOX 19018
100 W. RANDOLPH ST
SPRINGFIELD IL 62794-9018
CHICAGO, IL 60601-3274
• Payment must be made electronically. You are required to maintain bank account information with the department that we
will use to initiate and obtain payment for your cigarette tax stamps.
• The Illinois Department of Revenue is not responsible for stamps lost in transit.
• If you need assistance, call our Springfield office at 217 785-6613 or 217 524-5409 or our Chicago office at 312 814-3225.
• You can use MyTax Illinois to complete your order electronically at tax.illinois.gov.
Step 1: Provide your information
Name: ____________________________________________
Account ID: __ __ __ __ __ __ __ __
Street address: _____________________________________
License number: ___________________________
_______________________________________________
City
State
ZIP
Step 2: Tell us your order by multiplying the number of stamps you need by the stamp price
20 cigarettes per package - Order machine stamps in rolls (30,000 per roll)
1
1 _____________
Number of rolls ______________ X 30,000 = Number of stamps ______________X <1.98>
=
25 cigarettes per package - Order machine stamps in rolls (4,800 stamps per roll)
2
2 _____________
Number of rolls ______________ X 4,800 = Number of stamps ______________ X <2.475> =
Step 3: Figure the amount due
3
3 _____________
Add Lines 1 and 2 - Total amount due for stamps.
4
4 _____________
Write the amount of credit you wish to apply.
5
5 _____________
Subtract Line 4 from Line 3.
6
6 _____________
Total purchases from Line 7 of your last order invoice that represents accumulated stamp purchases from July 1.
7
7 _____________
Add Lines 5 and 6 - Total year-to-date purchase.
Use the worksheet on the back of this form to figure your discount
8
8 _____________
Discount amount (from the worksheet)
9
9 _____________
Subtract Line 8 from Line 5 - We will initiate and obtain an electronic payment for this amount.
DO NOT make a payment when you file this form.
Step 4: Sign below
I hereby authorize the Illinois Department of Revenue to electronically initiate a funds transfer as payment for purchase of cigarette tax
stamps against the bank account that was designated by the business listed above. I certify that I have the authority to authorize this
transfer.
____________________________________________________
___________________________________
Signature of person authorizing electronic funds transfer
Title
*343121110*
____________________________________________________
___/___/______
Printed name of person authorizing the electronic funds transfer
Date
Official Use
Do not write below this line
Picked up by:
______ Carrier
______ Agent
Shipped by:
______ Express
______ Registered
______ Insured
Checked by:
______
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 required.
Failure to provide information may result in this form not being processed and may result in a penalty.
RC-1-A (R-04/13)
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