Form Pt-16 - Pull Tabs And Jar Games Supplier'S Quarterly Report
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Illinois Department of Revenue
PT-16
Pull Tabs and Jar Games
Supplier’s Quarterly Report
Do not write above this line.
Read this information first
For each sale or delivery of pull tabs, you must give a receipt
You must maintain all books and records relating to the sale of
to your purchaser. Each receipt must include
pull tabs for a period of three years.
the date of sale or delivery;
This report must be signed and dated by a responsible officer
your name and license number;
of your organization and submitted within 30 days after the
the name and license number of the pull tabs purchaser;
end of the calendar quarter. Failure to comply will result in
the name of the pull tabs manufacturer; and
actions against your license up to and including revocation.
the serial number and ideal gross receipts for each
game.
Step 1: Identify your business
PS –
Business name
Pull tabs supplier’s license no.
_________________________________________
_____________________
Mailing address
For the quarter ending
_________________________________________
______/ ______/ ______
Number and street
Month
Day
Year
_______________________________________________________
City
State
ZIP
Step 2: Complete the following information
Did you sell or deliver pull tabs to persons or organizations
If “no,” initial the statement below.
located in Illinois during this reporting period?
______ No pull tabs were sold or delivered to persons or
organizations located in Illinois during this reporting
yes
no
period.
If “yes,” attach to this report a copy of each receipt as
described in “Read this information first” and initial the
statement below.
______ Receipts attached to this report reflect all pull tabs
sold or delivered to persons or organizations located
in Illinois during this reporting period.
Step 3: Sign below
Under penalties of perjury, I state that I have examined this
Mail this report to:
report and, to the best of my knowledge, it is true, correct, and
OFFICE OF BINGO AND CHARITABLE GAMES
complete. I further certify that the information contained in this
ILLINOIS DEPARTMENT OF REVENUE
report is taken from the records of the organization for which it
PO BOX 19480
is filed and that no other sales, authorized or unauthorized,
SPRINGFIELD IL 62794-9480
were made during the quarter covered by this report.
_______________________________________________________
If you have questions, call us at 217 524-4164
Responsible party’s signature
_______________________________________________________
Title
_______________________________________________________
Date
This form is authorized as outlined by the Pull Tabs and Jar Games Tax Act. Disclosure of this information is REQUIRED. Failure to provide
SOY-BASE INK
PT-16 (R-7/02)
information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-2685
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