Form Rb-1 - Bingo Quarterly Tax Return
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1
2Illinois Department of Revenue
REV 1
E S ___/___/____
RB-1
Bingo Quarterly Tax Return
NS DP CA
Do not write above this line.
Step 1: Identify your organization
For which quarter are you filing this return? _______
Bingo license number:___________________________________
Is this an amended return?
___yes ___no
Organization’s name:____________________________________
Sequence no. _____________________________
Has your organization’s address changed since your
Address: _____________________________________________
Number and street
last return?
___yes ___no
____________________________________________________
A "final” return indicates that an organization does not
City
State
ZIP
intend to conduct any more bingo games. Is this a final
return?
___yes ___no If "yes," write the date of
your final bingo game:___/___/____
Step 2: Identify your supplier
Did you purchase any bingo supplies or equipment this quarter?
___yes ___no
If “yes,” complete the following information:
Supplier's license no.: BF – _________________________________
Supplier's license no. BF – _________________________________
Supplier's name________________________________________
Supplier's name________________________________________
Address _____________________________________________
Address______________________________________________
Number and street
Number and street
_________________________________________________________________________
_________________________________________________________________________
City
State
ZIP
City
State
ZIP
Step 3: List your weekly games
Session date
Value of
Session date
Value of
Session date
Value of
Month/Day/Year
prizes awarded
Month/Day/Year
prizes awarded
Month/Day/Year
prizes awarded
1
6
11
____/____/_____
____________l___
____/____/_____
____________l___
____/____/_____
____________l___
2
7
12
____/____/_____
____________l___
____/____/_____
____________l___
____/____/_____
____________l___
3
8
13
____/____/_____
____________l___
____/____/_____
____________l___
____/____/_____
____________l___
4
9
14
____/____/_____
____________l___
____/____/_____
____________l___
____/____/_____
____________l___
5
10
Total games held
____/____/_____
____________l___
____/____/_____
____________l___
____________l___
Step 4: Figure your tax due
Value of
prizes awarded
No. players
Gross proceeds
15
15
Total number of players and gross proceeds for weekly games
__________
__________|__
16
________l__
16
Special permit no. 1_________________
__________
__________|__
Valid from ____/____/_____ to ____/____/_____
17
________l__
17
Special permit no. 2_________________
__________
__________|__
Valid from ____/____/_____ to ____/____/_____
18
________l__
18
County or state fair totals
__________
__________|__
Fair dates ____/____/_____ to ____/____/_____
19
19
Add Lines 15, 16, 17, and 18, Gross proceeds column. This is your tax base.
__________|__
20
20
Multiply Line 19 by 5% (.05). This is your bingo tax due.
__________|__
21
21
Total credit you wish to apply
__________|__
22
22
Subtract Line 21 from Line 20. Please pay this amount.
__________|__
Make your check payable to "Illinois Department of Revenue."
Step 5: Sign below
Under penalties of perjury, I state that I have examined this return and that it is true, correct, and complete, and that the total value of the prizes or merchandise
awarded on any day was not greater than $2,250 ($3,250 in Madison, Monroe, and St. Clair counties and the City of Red Bud).
_____________________________________(_____)____________________________
Mail this return and your payment to:
Officer's signature
Phone
Date
BINGO TAX
ILLINOIS DEPARTMENT OF REVENUE
_____________________________________(_____)____________________________
PO BOX 19019
Paid tax preparer’s signature
Phone
Date
SPRINGFIELD IL 62794-9019
RB-1 front (R-12/00)
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