Form Rcoa-1-A - Coin-Operated Amusement Device Schedule
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Illinois Department of Revenue
RCOA-1-A
Coin-Operated Amusement Device Schedule
Page _____ of _____
Read this information first
•
You must complete and attach this schedule to your completed Form RCOA-1, Coin-Operated Amusement Device Tax Decal Order Form.
If you are ordering more decals than provided for on this schedule, make additional copies of this schedule. If you wish to submit a
computer-generated version, you must first obtain our approval of your format.
•
We cannot issue a decal until Columns A through D are completed for each machine for which you are ordering decals. Failure to attach
a completed schedule to Form RCOA-1 may result in a penalty and seizure of unlicensed machines.
Step 1:
Identify your business
1
2
Name: ______________________________________________________
Date:__ __ /__ __ /__ __ __ __
3
4
Account ID: ___ ___ ___ ___ ___ ___ ___ ___
License no. : AD - ___ ___ ___ ___ ___
Step 2:
Identify each machine and its location
Machine code required for Column A:
8a
8b
8c
Jukeboxes
Mechanical rides
Pinballs
8d
8e
8f
Pool games
Redemption machines
Shuffleboards
8g
8h
8i
Video games - amusement
Video games - simulated gaming
Other
A
B
C
D
C
ode
Machine serial no.
Display/operation date
Complete address where machine will be displayed
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
*048501110*
Official Use - Do not write below this line
RCOA-1A front (R-04/10)
Batch no. of RCOA-1: ______________________________ Confirmation number: _______________________________
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