Form Rcoa-1-A - Coin-Operated Amusement Device Schedule Page 2
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2*048502110*
Step 2:
Identify each machine and its location
(continued)
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
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
RCOA-1A back (R-04/10)
This form is authorized as outlined by the Coin-Operated Amusement Device and Redemption Machine Tax Act. Disclosure of this information is
REQUIRED. Failure to provide information could result in penalties. This form has been approved by the Forms Management Center. IL-492-0023
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Parent category: Financial