Form Ds-1-X - Amended Dry-Cleaning Solvent Tax Return

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Illinois Department of Revenue
REV 04 Form 164
DS-1-X
E S ___/___/___
Amended Dry-Cleaning Solvent Tax Return
NS DP CA RC
Station no. 243
Identify your business
Do not write above this line.
Name
______________________________________________
Account ID:___ ___ ___ ___ ___ ___ ___ ___
License no.: DS - ___ ___ ___ ___ ___
Address
______________________________________________
Number and street
______________________________________________
This return is for the quarter ending ___ ___/___ ___ ___ ___
City
State
ZIP
Month
Year
Step 1:
Correct your financial information - Figures as they should have been reported
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.
$______________________
14
14
Figure your discount.
*216401110*
$______________________
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 net tax due.
$______________________
18
18
Total amount you paid for this reporting period.
$______________________
19
19 If Line 18 is greater than Line 17, subtract Line 17 from Line 18. This is the amount you have overpaid.
$______________________
2 0
If Line 18 is less than Line 17, subtract Line 18 from Line 17. This is the amount you have underpaid.
20
Pay this amount. Make your check payable to “Illinois Department of Revenue.”
$______________________
Step 4: Check the reason you are filing this amended return
I paid tax on receipts in error because the solvents were sold
to an Illinois business for resale. License no. is DS - ___ ___ ___ ___ ___.
to an out-of-state customer (interstate commerce sale) and the solvent was delivered outside of Illinois.
to an exempt organization. Tax exempt no.: E-____________________________
and exempt from tax. Explain:___________________________________________________________________________________
and returned by the customer.
I made a computation error.
The original License no. was incorrect. The incorrect License no. is DS - ___ ___ ___ ___ ___.
The original reporting period was incorrect. The incorrect reporting period is ___________________________.
Other. Please explain. ___________________________________________________________________________________________
Step 5:
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.
____________________________________________________
This form is authorized as outlined under the tax or fee Act
Taxpayer’s signature
Telephone
Date
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-X front (R-10/12)
Tax preparer’s signature
Telephone

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