Form Rcoa-1 - Coin-Operated Amusement Device Tax Decal Order Form
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1Illinois Department of Revenue
Station no. 607
RCOA-1
Coin-Operated Amusement Device Tax Decal Order Form
Read this information first -
A $30 tax decal must be purchased annually on or before July 31st for each qualifying coin-operated
amusement device (COAD) and redemption machine you operate/display to be played/operated by the public at a place you either own or
lease. Warnings: 1) If you operate/display these COAD and redemption machines without tax decals, you will be subject to a penalty and the
machines may be seized. 2) The Video Gaming Act provides that certain simulated gaming devices are subject to seizure, confiscation, and
destruction under the act, even if the devices are operated for amusement only and bear a current Coin-Operated Amusement Device decal.
*See back page for more information.
Step 1:
Identify your business
1
4
Name:
_____________________________________________
Account ID: __ __ __ __ __ __ __ __
2
5
Address:
___________________________________________
FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
Number and street
Federal Employer Identification number
6
__________________________________________________
Social Security number (if no FEIN):__ __ __ - __ __ - __ __ __ __
City
State
ZIP
❐
3
7
Check here if your address has changed.
COAD Tax ID: AD - __ __ __ __ __
Step 2:
Tell us the number of tax decals you are ordering
8
8a
Write the number of tax decals you need to order on the line
_____ jukeboxes
8b
next to the type of machine for which you are ordering tax decals.
_____ mechanical rides
Note:
8c
You must also complete and attach Form RCOA-1-A to
_____ pinballs
8d
identify each machine for which you are ordering a tax decal.
_____ pool games
8e
_____ redemption machines
8f
_____ shuffleboards
8g
_____ video games - amusement
(e.g., Pac Man, Golf)
8h
_____ video games - simulated gaming
(e.g., poker, blackjack)*
8i
_____ other (brief description)
____________________________________________
9
9
Add Line 8a through 8i. This is the total number of tax decals you need to order (Step 4, Line 11).
___________________________
Step 3:
Tell us the tax year for which you are ordering tax decals
10
August 1, 20__ __ to July 31, 20 __ __
Year
Year
Step 4:
Figure your tax
11
11
Number of tax decals you need to order (the total number from Step 2, Line 9).
___________________________
12
12
Multiply Line 11 by $30.
$_________________________
13
13
Penalty (if applicable). See instructions.
$_________________________
14
14
Add Lines 12 and 13. This amount is your total tax and penalty.
$_________________________
15
15
Write the amount of credit you wish to apply.
$_________________________
16
16
Subtract Line 15 from Line 14. This is the total amount due.
$_________________________
Make your check payable to “Illinois Department of Revenue (COAD).”
Step 5:
Sign below
Under penalties of perjury, I state that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
(_____)_____ - _____________
__ __/__ __/__ __ __ __
Signature
Daytime telephone
Date
Step 6:
Mail your order form or WebFile at tax.illinois.gov.
Mail your completed Form RCOA-1, Form RCOA-1-A, and payment to us at
SPRINGFIELD CASHIERING OPERATIONS SECTION
*248421110*
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19019
SPRINGFIELD IL 62794-9019
Do not write below this line.
Decal no.
________________
Date issued
/
/
Clerk ID ___________________
__ __
__ __
__ __ __ __
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-1 front (R-11/12)
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