Form Pt-12 - Expenditures Of Pull Tab Funds
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1
2Illinois Department of Revenue
PT-12
Expenditures of Pull Tab Funds
Step 1: Identify yourself
Name ____________________________________________
Reporting period: From ____/_____/____ To ____/____/____
month
day
year
month
day
year
Address __________________________________________
Pull Tab License P-___________
_________________________________________________
Telephone no. (_____) ______-__________
Note: Please follow the instructions on the back of this form.
Step 2: Figure your pull tab proceeds
1 Gross proceeds from pull tabs during reporting period
1 ____________________________
2 Cash prizes awarded
2 ____________________________
3 Subtract Line 2 from Line 1. Net proceeds (deposited in pull tab checking account)
3 ____________________________
4 Other deposits in pull tab checking account
4 ____________________________
5 Balance in pull tab checking account at start of reporting period
5 ____________________________
6 Add Lines 3, 4, and 5
6 ____________________________
7 Dollar amount of all checks written on pull tab checking account and all other
charges to pull tab checking account during reporting period
7 ____________________________
8 Subtract Line 7 from Line 6
8 ____________________________
9 Balance in pull tab checking account at end of reporting period
9 ____________________________
Line 9 should equal Line 8. If the amounts are not identical, please explain the discrepancy here:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Step 3: List your checks and charges
Note: Please write your checks in sequential order and attach additional sheets if necessary.
_____________________________________________________________________________________________________
Check number
Amount
Person or organization
Purpose
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This form is authorized as outlined by the Illinois Pull Tabs and Jar Games Act. Disclosure of this information is REQUIRED. Failure to provide
information could result in this form not being processed. This form has been approved by the Forms Management Center.
IL-492-2683
PT-12 front (R-5/00)
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