Illinois Department of Revenue
DS-1
REV 05 Form 160
Dry-Cleaning Solvent Tax Return
E S
___/___/___
NS DP CA RC
Do not write above this line.
Identify your business
Name
______________________________________________
Account ID: ___ ___ ___ ___ ___ ___ ___ ___
License no.: DS - ___ ___ ___ ___ ___
Address ______________________________________________
Number and street
This return is for the quarter ending ___ ___/___ ___ ___ ___
______________________________________________
Month
Year
City
State
ZIP
Step 1: Figure your tax on sales of dry-cleaning solvents
1
Chlorine-based solvents:
a
1a
Total gallons sold.
_______________________
b
1b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
1c
Subtract Line 1b from Line 1a for net gallons sold subject to tax.
_______________________
d
1d
Multiply Line 1c by $10.00 for your tax on chlorine-based solvents.
$______________________
2
Petroleum-based solvents:
a
2a
Total gallons sold.
_______________________
b
2b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
2c
Subtract Line 2b from Line 2a for net gallons sold subject to tax.
_______________________
d
2d
Multiply Line 2c by $2.00 for your tax on petroleum-based solvents.
$______________________
3
Green solvents sold that are not for use in virgin facilities:
a
3a
Total gallons sold.
_______________________
b
3b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
3c
Subtract Line 3b from Line 3a for net gallons sold subject to tax.
_______________________
d
3d
Multiply Line 3c by $1.75 for your tax on these solvents.
$______________________
4
Green solvents sold for use in virgin facilities:
a
4a
Total gallons sold.
_______________________
b
4b
Total gallons sold tax-free to qualifying facilities.
_______________________
c
4c
Subtract Line 4b from Line 4a for net gallons sold subject to tax.
_______________________
d
4d
Multiply Line 4c by $0.35 for your tax on these solvents.
$______________________
Step 2: Figure your tax on purchases of dry-cleaning solvents
5
Total gallons of chlorine-based solvents purchased from an
5
unregistered out-of-state supplier.
_______________________
6
6
Multiply Line 5 by $10.00 for your tax on chlorine-based solvents.
$______________________
7
Total gallons of petroleum-based solvents purchased from an
7
unregistered out-of-state supplier.
_______________________
8
8
Multiply Line 7 by $2.00 for your tax on petroleum-based solvents.
$______________________
9
Total gallons of green solvents purchased from an unregistered
9
out-of-state supplier and which are not for use in a virgin facility.
_______________________
1 0
10
Multiply Line 9 by $1.75 for your tax on these solvents.
$______________________
11
Total gallons of green solvents purchased from an unregistered
11
out-of-state supplier for use in a virgin facility.
_______________________
1 2
12
Multiply Line 11 by $0.35 for your tax on these solvents.
$______________________
Step 3: Figure your amount due
1 3
13
Add Lines 1d, 2d, 3d, 4d, 6, 8, 10, and 12.
$______________________
*216001110*
14
14
Figure your discount. See Step-by-Step instructions.
$______________________
15
15
Subtract Line 14 from Line 13. This is your total tax due.
$______________________
16
16
Credit you wish to apply.
$______________________
17
17
Subtract Line 16 from Line 15. This is your total amount due.
$______________________
Step 4: Sign below
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
______________________________________________________
Taxpayer’s signature
Telephone
Date
Tax preparer’s signature
Telephone
Date
Mail Form DS-1 and payment to: Dry-Cleaning Solvent Tax, Illinois Department of Revenue, PO BOX 19019, Springfield IL 62794-9019
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this information is
required. Failure to provide information may result in this form not being processed and may result in a penalty.
DS-1 front (R-10/12)