Form Rc-1-A - Cigarette Tax Stamp Order-Invoice - Illinois
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Illinois Department of Revenue
RC-1-A
Cigarette Tax Stamp Order-Invoice
Read this information first
Orders will be filled at your assigned location only:
101 W JEFFERSON ST
- or -
CONCOURSE 300
PO BOX 19018
100 W. RANDOLPH ST
SPRINGFIELD IL 62794-9018
CHICAGO, IL 60601-3274
Payment must be made by means of Electronic Funds Transfer (EFT).
The Illinois Department of Revenue is not responsible for stamps lost in transit.
If you need assistance, call our Springfield office at 217 782-6045 or our Chicago office at 312 814-3225.
Step 1: Provide your information
Name:____________________________________________
Account ID: __ __ __ __-__ __ __ __
Street address: _____________________________________ License number: ___________________________
_______________________________________________
City State ZIP
Step 2: Tell us your order by multiplying the number of stamps you need by the stamp price
20 cigarettes per package -
Order machine stamps in rolls (30,000 per roll)
1
1 _____________
Number of rolls ______________ X 30,000 = Number of stamps ______________X .98 =
25 cigarettes per package -
Order machine stamps in rolls (4,800 stamps per roll)
2
2 _____________
Number of rolls ______________ X 4,800 = Number of stamps ______________ X 1.225 =
Step 3: Figure the amount due
3
3
_____________
Add Lines 1 and 2 - Total amount due for stamps.
4
4
_____________
Write the amount of credit you wish to apply.
5
5
_____________
Subtract Line 4 from 3.
6
6
_____________
Total purchases from Line 7 of your last order invoice that represents accumulated stamp purchases from July 1.
7
7
_____________
Add Lines 5 and 6 - Total year-to-date purchase.
U se the worksheet on the back of this form to figure your discount
8
8
_____________
Discount amount (from the worksheet)
9
9
_____________
Subtract Line 8 from Line 5 - pay this amount by Electronic Funds Transfer (EFT).
Step 4: Sign below
I hereby authorize the Illinois Department of Revenue to electronically initiate a funds transfer as payment for purchase of cigarette tax
s tamps against the bank account that was designated by the business listed above. I certify that I have the authority to authorize this
transfer.
____________________________________________________ ___________________________________
Signature of person authorizing electronic funds transfer
Title
____________________________________________________ ___/___/______
Printed name of person authorizing the electronic funds transfer
Date
*043101110*
Official Use
Do not write below this line
Picked up by:
_ _____ Carrier
______ Agent
Shipped by:
_ _____ Express
______ Registered _ _____ Insured
Checked by:
_ _____
This form is authorized as outlined by the Cigarette and Cigarette Use Tax Acts. Disclosure of this information is REQUIRED. Failure to
RC-1-A (R-04/10)
provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-2285
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