Form Pt-11 - Limited Pull Tabs And Jar Games Tax Return
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1
2Illinois Department of Revenue
REV 1
PT-11
E S ___/___/____
Limited Pull Tabs and
NS DP CA
Jar Games Tax Return
Station no. 995
Do not write above this line.
Tell us about your organization and account activity
1
Pull tabs license no. PL-___________________________
When did you sell pull tabs?
From _ _/_ _/_ _ _ _ to _ _/_ _/_ _ _ _
Month Day
Year
Month Day
Year
___________________________________________________________
2
Organization’s name
Is this an amended return?
___________________________________________________________
yes ____ no ____
In-care-of name
3
___________________________________________________________
Has your address changed since your last
Number and street
filing? yes ____ no ____
___________________________________________________________
4
City
State
ZIP
Did you sell any pull tabs this event?
yes ____ no ____
If “no,” go to Step 3.
If “yes,” go to Step 1 on the back of
this form.
Step 1: Figure your gross proceeds
(Step 1 is on the back of this form.)
Step 2: Figure your tax
(You must complete Step 1 on the back of this form before you complete Step 2.)
1
1
Gross proceeds. Enter the total of Step 1 Column J.
_________________________|______
2
2
Total tax due. Multiply Line 1 by 5% (.05), and enter the result here.
_________________________|______
3
3
Total amount of credit you wish to apply
_________________________|______
4
4
Total due. Subtract Line 3 from Line 2. Pay this amount.
_________________________|______
Make your check payable to “Illinois Department of Revenue.”
Step 3: Sign below
Under penalties of perjury, I state that I have examined this return and that it is true, correct, and complete, and that the total value of the
prizes or merchandise awarded on any day was not greater than $5,000.
__________________________________________________ (____)___________________ _______________________
Taxpayer or authorized officer’s signature
Daytime telephone number
Date
__________________________________________________ (____)___________________ _______________________
Paid tax preparer’s signature
Daytime telephone number
Date
Mail your completed return and payment to:
PULL TAB 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.
PT-11 front (R-06/15)
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