Form Rc-16 - Cigarette Tax Claim For Credit

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Illinois Department of Revenue
REV 00 FORM 447
RC-16
Cigarette Tax Claim for Credit
Step 1: Identify the claimant
Name ________________________________________________
Account ID:___ ___ ___ ___ ___ ___ ___ ___
Address ________________________________________________
License no.: ___ - ___ ___ ___ ___ ___
Number and street
Title _____________________________________________
________________________________________________
City
State
ZIP
President, secretary, partner, sole owner, or manager
___________________________ (____)______________
County
Telephone number
Step 2: Describe your claim
1
I am filing this claim for
stamps affixed to unusable packages of cigarettes or little cigars that I returned to the manufacturer. (Complete Columns A, B, C,
and D below.)
unusable stamps that I returned to the Illinois Department of Revenue. (Complete Columns A, B, and D below and enclose the stamps.)
a shortage on a cigarette stamp roll. (Complete Columns A, B, and D below and enclose the remainder of the roll.)
another reason. (Explain the reason and complete Columns A, B, and D below.)
__________________________________________________________________________________________________________
A
B
C
D
Number of sticks
Number of stamps
Series and denomination
in each package
Dollar value
__________________________ ___________________________ __________________________
________________________
__________________________ ___________________________ __________________________
________________________
__________________________ ___________________________ __________________________
________________________
__________________________ ___________________________ __________________________
________________________
Total
_________________________
2
Date, as indicated on the bill of lading, that stamps were returned to the manufacturer __ __/__ __/__ __ __ __
3
Stamps returned to _____________________________________________________________________________________________
Name
_____________________________________________________________________________________________
Street address
City
State
ZIP
Step 3: Sign below
Mail your completed claim to:
ALCOHOL, TOBACCO AND FUEL DIVISION
Under penalties of perjury, I state that I have examined this claim
ILLINOIS DEPARTMENT OF REVENUE
and, to the best of my knowledge, it is true, correct, and complete.
PO BOX 19477
SPRINGFIELD IL 62794-9477
_______________________________________________________
Signature of owner, partner, officer, or authorized agent
Date
If you have questions, call us weekdays between 8:00 a.m. and
4:00 p.m. at 217 782-6045.
*344701110*
Do not write below this line.
Credit memo no. ____________
Credit amount $_____________
Verified by _______________________________ Date__________
Reviewed by _____________________________ Date__________
Approved by ______________________________ Date__________
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-16 (R-07/13)

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