Form Pt-10 - Pull Tab And Jar Game Quarterly Tax Return - 2001
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Illinois Department of Revenue
PT-10
Pull Tab and Jar Game
Quarterly Tax Return
Station 994*
Step 1: Tell us about your organization and account activity
Quarter ending
__ __ __ __ __ __ __ __
Month
Day
Year
1
Pull tabs license no. P - ___________________________
Is this an amended return?
yes ____ no ____
*Station 995
___________________________________________________________
Organization's name
2
Is this a final return? yes ____ no ____
___________________________________________________________
If “yes,” your license will be cancelled.
C/O
Note: A “final” return indicates that an organization
___________________________________________________________
does not intend to conduct any more events.
Number and street
3
___________________________________________________________
Has your address changed since your last
City, state, ZIP
filing? yes ____ no ____
4
Did you sell any pull tabs this quarter?
yes ____ no ____
If “no,” go to Step 4.
If “yes,” go to Step 2 on the back of this
form.
Step 2: Figure your gross proceeds
(Step 2 is on the back of this form.)
Step 3: Figure your tax
(You must complete Step 2 on the back of this form before you complete Step 3.)
1
1
Gross proceeds. Write the total of Step 2, Column J.
_______________________________
2
Did you have a special permit? yes ____ no ____ (If “no,” go to Line 3.)
If “yes,” write your special permit number here. PX - ___________________
Write the dates this permit was issued for
to
____ ____ ______
____ ____ ______.
Month Day
Year
Month Day
Year
How many games were played under the special permit?_________________
(Do not write number of days sold.)
3
3
Total tax due. Multiply Line 1 by 5% (.05).
_______________________________
4
Write the number and amount of each credit memorandum you want
to apply against tax due. You must attach your original memorandum.
Credit number
Credit amount
a
_______________________
______________________
b
_______________________
______________________
c
_______________________
______________________
4
Add Lines a, b, and c and write the result on Line 4.
_______________________________
5
5
Total due. Subtract Line 4 from Line 3.
_______________________________
Make your check payable to “Illinois Department of Revenue.” (Pay this amount.)
Step 4: Sign below
(You must sign and date your return.)
Under penalties of perjury, I state that I have examined this return; it is true, correct, and complete; and the total value of the prizes or merchan-
dise awarded on any day did not exceed $5,000.
__________________________________________________
(____)___________________
_______________________
Taxpayer or authorized officer’s signature
Daytime telephone number
Date
__________________________________________________
(____)___________________
_______________________
Paid tax preparer’s signature
Daytime telephone number
Date
Note: If you do not sign your return, it will be deemed as not filed and you may be subject to penalties as provided by law.
Mail your completed form and payment to:
Pull Tab Tax, Illinois Department of Revenue, P.O. Box 19019, Springfield, IL 62794-9019.
This form is authorized by the Illinois Pull Tabs and Jar Games Act. Disclosure of this information is required. Failure to
PT-10 front (R-1/01)
comply may result in a penalty. This form has been approved by the Forms Management Center.
IL-492-2396
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