Form Rg-6-X - Amended Assistance Charges Return For Natural Gas Distributors
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REV 3
Form 555
Illinois Department of Revenue
E S ___/___/___
RG-6-X
Amended Assistance Charges Return for Natural Gas Distributors
NS
DP
CA
Station 257
Do not write above this line.
Identify your business
Liability period ___ ___/___ ___ ___ ___
Account ID __ __ __ __ __ __ __ __
Month
Year
Check here if your address has changed.
FEIN
___ ___ - ___ ___ ___ ___ ___ ___ ___
Federal employer identification number
Is this a final (you are no longer in business) return?
yes
no
License no. GA - ___ ___ ___ ___ ___
Name
______________________________________________
Address
____________________________________________
Number and street
___________________________________________________
City
State
ZIP
Step 1: Figure your assistance charges due - Figures as they should have been filed
Total number
Energy
Renewable
of accounts
Assistance Charge
Energy Charge
1
Total number of accounts to which you delivered residential gas
service and from which you collected the assistance charges
1
during this liability period.
_____________
2
2 Multiply Line 1 by the appropriate rate - See instructions.
__________|___
3
3 Multiply Line 1 by $0.05.
__________|___
4
Write the total number of accounts
• to which you delivered nonresidential gas service,
• to which you delivered less than 4 million therms of gas during
the previous calendar year, and
• from which you collected the assistance charges.
4
_____________
5
5
Multiply Line 4 by the appropriate rate - See instructions.
__________|___
6
6
Multiply Line 4 by $0.50.
__________|___
7
Write the total number of accounts
• to which you delivered nonresidential gas service,
• to which you delivered 4 million or more therms of gas during the
previous calendar year, and
• from which you collected the assistance charges.
7
_____________
8
8
Multiply Line 7 by the appropriate rate - See instructions.
__________|___
9
9
Multiply Line 7 by $37.50
__________|___
10
10
Energy Assistance Charge - Add Lines 2, 5, and 8.
__________|___
10a
10a
Arrearage Reduction Program subtraction.
__________|___
10b
10b
PIPP Program Administrative & Operation Expense Subtraction.
__________|___
10c
10c
Add Lines 10a and 10b and subtract from Line 10 for your total Energy Assistance Charge.
__________|___
1 1
11
Add Lines 3, 6, and 9. This amount is your total Renewable Energy Charge due.
__________|___
12
12
Add Lines 10c and 11. This amount is the total assistance charge due.
__________|___
13
13
Total amount you paid for this reporting period.
__________|___
14
14
If Line 13 is greater than Line 12 — Subtract Line 12 from Line 13 for your overpayment.
__________|___
15
15
If Line 13 is less than Line 12 — Subtract Line 13 from Line 12 for your underpayment.
__________|___
Pay this amount and make your check payable to “Illinois Department of Revenue.”
Step 2:
Check the reason you are filing this amended return
❑
I made a computation error that resulted in an overpayment of tax.
• If you checked this box, did you collect the overpaid tax from your customer?
yes
no
• If you checked “yes,” did you unconditionally refund the overpaid tax?
yes
no
❑
I made a computation error that resulted in underpayment of tax.
❑
I should have taken a deduction for ____________________________________________________________________________
❑
The original License no. was incorrect. The incorrect License no. is GA - ___ ___ ___ ___ ___.
❑
The original reporting period was incorrect. The incorrect reporting period is ___________________________.
❑
Other. Please explain._______________________________________________________________________________________
________________________________________________________________________________________________________
______________________________________________________________________________________________
Step 3:
Sign below
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.
_____________________________
________________
(____)____-___________
____/____/________
Title:
Taxpayer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
_____________________________
________________
(____)____-___________
____/____/________
Firm:
Preparer’s signature and name of the firm or employer (if applicable)
Telephone number (include area code)
Date
*255501110*
This form is authorized by the Energy Assistance Act of 1989 and the Renewable Energy, Energy Ef-
ficiency, and Coal Resources Development Law of 1997. Disclosure of this information is required.
RG-6-X (R-11/12)
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