Form Rcoa-19 - Coin-Operated Amusement Device Tax Decal Claim For Credit
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1Illinois Department of Revenue
RCOA-19
Coin-Operated Amusement Device Tax Decal
Claim for Credit
Step 1: Identify your business
1
Name: ________________________________________ 4 Account ID: ___ ___ ___ ___ ___ ___ ___ ___
2
Mailing address: ________________________________
5 FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
______________________________________________ 6 SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
3 Phone no.:(___ ___ ___)___ ___ ___ - ___ ___ ___ ___
7 COAD Tax ID: AD - ___ ___ ___ ___ ___
Step 2: Check the reason you are filing this claim
❒
8
Receive credit for decals I want to transfer. Number of decals:_______
8a Multiply the number of decals by $30. Write that amount here and in Step 3, Line 17.
8a $_______________
8b Serial numbers: __________ __________ __________ __________ __________ __________ __________
__________ __________ __________ __________ __________ __________ __________
❒
9
Overpaid when ordering decals (Form RCOA-1).
❒
10
Duplicate order.
❒
11
Other. Provide a detailed explanation of your claim. Attach additional sheets if needed.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Step 3: Complete the following information
2 0
2 0
12
Year of the tax decal for which you are filing this claim: August 1,
___ ___ to July 31,
___ ___
Note: If you completed Step 2, Line 8a, skip to Line 17 (total from Line 8a).
Column A
Column B
As Originally Filed
Corrected Amounts
13
Number of tax decals you purchased.
13 ________________
13 ________________
14
Amount of tax you paid.
14 ________________
14 ________________
15
Amount of penalty you paid
15 ________________
15 ________________
16
Total amount. Add Lines 14 and 15.
16 ________________
16 ________________
17
Subtract Column B, Line 16 from Column A, Line 16. This is the amount of your credit.
17 ________________
Step 4: Sign here
- A claim will not be processed without a signature.
Under penalties of perjury, I state that I have examined this claim and that it is true, correct, and complete.
__________________________________________________
Official Use
Signature
Date
No
____________
Mail to:
SPRINGFIELD CASHIERING OPERATIONS SECTION
Amt
____________
ILLINOIS DEPARTMENT OF REVENUE
Apv
____________
PO BOX 19018
Vrf
____________
SPRINGFIELD IL 62794-9018
DR
____________
Int D
____________
For questions, call 217 785-6613 or 217 524-5409
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 may result in this form not being processed and may result in a penalty.
RCOA-19 (R-11/12)
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