### (



## ( APPENDIXD: Sample Sales TaxReturns
ST-1 Sales and UseTaxand E911 Surcharge Return ST-1-XAmended Sales andUseTaxand E9l l SurchargeRehm1 RMFT-5-US Underground StorageTank Tax and Environmental ImpactFeeReceiverReturn RMFT-5-US-XAmendedReturn/Claim forCreditUnderground StorageTank Tax and Environmental Impact Fee ScheduleC ScheduleD ScheduleE 

## Schedule DA Schedule DD Schedule LA Schedule LB Schedule LC 

## Schedule LD Schedule LE 

## Schedule SA Schedule SD 

## Schedule SE

### ((



## ( Illinois Departmentof Revenue 

# RMFT-5-US Underground StorageTankTax and Environmental Impact Fee Receiver Return REV 01 

### ES NS OP CA Do""',.,,,ie ab<>1•e th·r· ,o~ 

# Step 1 : Identifyyourself
Name Reporting period-~~--/ Month

- Yea,-

- Address~----- Nu~ber and street Receiver license number ~R~-------~ Telepl1one no.(
___ )
___ - ____ 

# c,, Siate 2'P Note: You must report your fuel in gallons. Convert liters to gallons by multiplying liters by .2641721. Follow our instructions for each column. 

# Step 2: Figure yourtotal gallonagefor the month Column 1 Gasoline and spe;::1al fuel 1 Enteryour actual (stick) inventory at the beginning of the month.This amount must 

### 1 -----

agree with closing inventory of preceding rnonth·s return. 

### 2 Enterthe number of invoiced gallons produced, acquired. received ortransported

into Illinois during the month a Tax/fee-free invoiced gallons 1scr~du1.e A. SA 0° DA. Cclurnn 1.sc~ed~ta LA. Column 21 2a ----- 

### b Tax/fee-paid invoiced gallons1s~~ed~J,a E. sec. or LE 1dyejd,esell. Co!u'Tir 1. otherfuel. Sch:,j~le LE. Column 21 

### 2b ----- 

### 3 Add Lines 1 through 2b and enterthe result in Line 

### 3. Rememberto do calculations

within each column. 

### 3

----- 

### 4 Enteryour actual (stick) inventory atthe end ofthe month. 

### 4

----- 5 Subtract Line 

### 4 from Line 

### 3 and enterthe result on Line 

### 5. You must account

for your nontaxable and taxable gallonage within Step 3 and Step 4. 

# Step 3: Figureyour nontaxable gallonage

6 Enterthe numberof gallons sold exempt in Illinois

a to railroads for direct rail operation 1schectu1e LBJ 

### b to qualified air carriers 1s~M.adule LB, ~erose~e. Column 1.other ruel, Co:umn 21 

### c to qualified ships, barges, and vessels (Scr.eduleLB1 

### 7 Enterthe number of gallons sold and delivered outside of !l!inois (Schedu:.ac. sc, DC. or LC) 

### 8 Enterthe numberof gallons sold and distributedtax/fee-free 

### to licensed receivers

(Sci'edule D, SD, or DD, Coi~m" 1, Sc~edJle LO. Columr 2) 

### 9 Enterthe numberof gallons of your loss due to temperature variation or evaporation



## oryour gain due totemperature variation. Complete Line 

### 9a or 9b per column. 

### 5

6a 

### 6b 6c



### 7 8 Column 2 Other iuels

!!II!/// if/iiiIi IIll!I lll!l!l!!l!llllll/1/II



## a Loss. The amount of tosses you claim are limited. See instructions. 

## or 9a ~---- ----- 

### 9b I I ~I---~ b Gain. 

### 1o Add Lines 6athrough 9b and enterthe result on Line 10. This is yourtotal nontaxable gallonage. 

# Step 4: Figure your gross taxable gallonage 11 Subtract Line 10from Line 5 and enterthe result on Line 11. This isyour grosstaxable gallonage. 

# Step 5: Figure your nettaxable gallonage 12 Enterthe numberof gallons on wh\ch tax/fee was paid atthetime of purchase. 13 Subtract Line 12 from Line 11 and enterthe result on Line 13. This is your nettaxable gallonage by fuel type. 1 Add Line 13, Column 1 and Line 13, Column 2 and enterthe result on Line 14.

This isyour nettaxable gallonage. 

### 10

11

12

----- ----- 

### 13

----- ----- 14
______ _

RMFT-S·US Paget IR·G6.'15) ti·s •crrn is asto~, zed ~s outi1no1 u~oe· the ta, c,r ree c! 1'npos.e'.' the tc,~r eetor w~c th,s ..,,, ,s lee<. ioc osweer th s ,- ormat10~ ·s cgqu:•eO Fa,-are to pr,o,iCl~ 1n!c,ma1,on may rnsdt ,~ \h'S foe,~ mlbeshQ p'OcessM a,~..,,~, ,eou,1 ,n a re,aity

# Form RMFT-5-US Page 2 Step 6: Figureyourtax andfee i5 Figure your gross tax and fee due. If the amount of Line 14 is greaterthan zero. 

### enterthe amount from Line 14 on the line provided below and multiply by the tax and fee rates provided. Otherwise, enter'·o" in Lines 1Sa. 15b. and 15c. 

### a For underground storage tank tax: X 0.003. 15a 

# s ____ _ Loe ,4 

### b For environmental impactfee: 

# -~=-- X 0.008- 

## 1sb s ___ _ ~ne ,~ 

### c 

### Add Lines 

### i Sa and i5b.

### This is your gross tax and fee due. 16 

### tf you are filing this return on time and paying your tax and fee due in full. figure your 

### 1.75°.-;, collection discount. Multiply Line 1Sc by 0.0175. 17 Subtract Line 16from Line 15c and enterthe result on Line 17. This is yourtax and fee due. 

# Step 7: Figurethe amountyou owe 18 Enterthe amount of credit you wish to apply. (See instructions.) 19 Subtract Line 18 from Line 17 and enterthe result on Line 19.This isthe 

## amount you owe. Make your check payable to "'Illinois Department of Revenue.'· 

# Step 8: Sign and dateyour return 15c$,
______ _ 

### 16$,
______ _ 17$,
______ _ 

## 1a s ______ _ 19 

### $
______ _
Under penalties of perjury. I state that J 

### have examined this r·eturn and, to the best of my knowledge, it is true, correct, and complete.
S1gm,1u,e ofpersor. vtrer 1raP taxpayer. wro preparejl~,s ,eturr Dale Prepo.rers phorenumt,e, Signature ard title ofmxpayer Or.le 

### Mail this return andpayment to: Illinois Department ofRevenue, PO Box 19019, Springfield, !L 62794-9019

Rl.1FT-5-US Pa~a 2 tR-03 15J

# Form RMFT-5-US Instructions General Information Who mustfile this return? If 

### you are a licensed receiver who first sells or uses fuel for any purpose, you must pay the underground storage tank tax (UST} and the environmental impactfee {EIF) at the time of such sale or 

### use. 

## When arethe return, schedules, and payment due? Your return is due on or before the 20111 day of each month for the previous month's activity.You must file a return by ihis due 

### date even wl1en you make tax- and fee-paid purchases or are inactive. Supporting schedules. documents, and payment must 

### accompany t11e return. Note: lfthe due date falls on a weekend or holiday, your payment 

### is due the next business day. 

## How do I file my return? For all reporting periods June2015 and after. you mayfile your return electronically through MyTax Illinois available on our website at tax.illinois.gov.

### You may pay electronically. For all reporting periods May 2015 and prior. makeyour check payable to "Illinois Department

### of Revenue" and mail your completed return and payment to: ( ,INOIS DEPARTMENT OF REVENUE



### r"0 BOX 19019 SPRINGFIELD IL 62794-9019 Write a separate check for paying your Form RMFT-S"US liability. Do not combine itwith any other liability you owe. 

## What

## if I have additional questions or need more information? Write to us at the address above or cal! us at our Springfield office weekdays between 8:00 a.m.and 4:30 p.m. at 217 782-2291 orvisit our website at tax.illinois.gov. 

## What records must I keep? You are required by lawto keep books and records showing all purchases, receipts, sales, distributions, and use offuel. 

## What

## if I do not comply? You owe a late-filing penalty if you do not file a processable return by the due date. a late-payment penalty 

### if you do not pay the taxltee you owe by the date the tax/fee is due, and a bad check penalty if your remittance is not honored by your financial institution. Interest is calculated on tax/fee from the day after the original due date of your return through the date you pay thetax/fee.We will bill you for penalties and interest. For more information about penalties and interest. see Publication 103, Penalties and Interestfor IllinoisTaxes, available on ourwebsite 

## ! ax.iUinois.gov.

If you do notfile a return. we may also revoke your license.

RMFT·5·US l'l.Wuct o~s 1wol (R-J6- 15) 

# Specific Instructions How do I convert gallonsto liters? You must report your fuel in gallons. Convert liters lo gallons by multiplying liters by .2641721. Line 2a • Column 1 - Enter the number of UST-/EIF-free gallons of gasoline and special fuel from Schedules A, SA, or DA. Column 2 - Enter the number oi UST-/EIF-free gallons of other fuels from Schedule LA. Line 2b• Column 

### 1 · Enter the number oi UST-/EIF-paid gallons of gasoline and special fuel 

### from Schedules E and SE. Also include your gallons of dyed diesel from Schedule LE. Column 2 - Enterthe number of UST-IEIF-paid gallons of other fuels from Schedule LE. Line Ga - Enter the number of UST-/EIF-free gallons of diesel fuel you sold to qualified railroads for direct rail operation from Schedule LB in Column 1. Line 

### 6b**~** Enter the number of UST-/EIF-free gallons of kerosene {other than 1-K kerosene) you sold to qualified aircarriers from Schedule LB in Column 

### 1. Report gallons of other fuel you sold to qualified air carriers from Schedule LB in Column 

### 2. Line 

### 6c
- Enterthe number of UST-/EIF-free gallons of diesel fuel you sold to qualified ships. barges, and vessels from Schedule LB in Column 

### 1. Lines 7 and 8 - Column 1 - Enterthe number of gallons of UST-/EIF-free gasoline and special fuel from Schedules C. SC. DC, 0, SD and DD. Column 2 - Enterthe number of UST-/EIF-iree gallons of otherfuels from Schedules LC and LO. Line 9 - This is the balancing figure on yourfuel tax/fee accounting and should. 

### ii al! other figures are correct. represent your gallonage adjustment dueto temperature variation or evaporation. Enter any loss in Line 9a, or enter any gain in Line 

### 9b. Line 9a:The loss amountyou may claim on Line 9a is limited.The limit is figured based on returns filed forthe liability periods of Januarythrough June and separately forJulythrough December of each year.The net loss is limited to 1 percent of the total gallons in storage at the beginning of each six-month period, plus the receipts of gallonage for each six month period. minus the amount of storage at the end of each six month period. Any loss exceeding the 1 percent limit is subject to the Underground StorageTankTax and Environmental Impact 

### Fee. Line 10 - Add Lines 6a though 9b. Note: Line 9b is a negative field.

# Form RMFT-5-US Instructions Specific Instructions Line12- Colurnn 1 - Enter the total number of gallons of gasoline and special fuel you purchased UST- and EIF-paid. Column 2 - Enter the total number of gallons of other fuels you purchased UST- and EIF-paid. Line 15a -The underground storage tax is 3tJOoi a cent (.003) per gallon of fuel. Mulliply Line 14 by .003 and enter tl1e result. Line 15b -The environmental impact fee rate is $60 per 7,500 gallons of fuel prorated to any portion. Multiply Line 14 by .008 and enterthe result. Line 16 - If you file your return and pay yourtax and fee infull on time, you 

### are allowed a collection discount.The collection 

### discount is 1.75 

### percent (.0175) of the 

### gross tax 

### and lee due. Multiply Line 15c, gross tax and fee due. by 1.75% (.0175) and enter the result. Line 18- If you have a credit memorandum and you wish to use it toward what you owe, enter the amount you are using. Line 1g - Subtract Line 18 from Line 17.This is the amount you owe. 

### If you do not file a processable return or pay the UST and EIF

### you owe by 

### the due date, you will owe penalty and interest. We will bill you for penalties and interest. For more information, see Publication 103 available on ourwebsite at tax.Illinois.gov.

Rr.1FT·5·LJS 1Ss1n,c!,ons t,ack (R-06:15) 

## (

## (

# {J Illinois DepartmentofRevenue 

# RMFT-5-US-X Amended Return/Claimfor Credit Underground StorageTankTax and Environmental Impact Fee Step 1: Identifyyourself REV01 ES HS DP CA 

## Name Original reporting period_~~--/-
___ l,1onth Year 

### Address
_____________________ _ Number and s1,eet 

### Receiver license number ~R~--------- Telephone no.{
___ }
___ - ____ City Slate ZIP Note: You must report yourfuel in gallons. Convert liters to gallons by 

## As originally reported Corrected multiplying liters by .2641721. Follow our instructions for each column. 

## or adjusted amounts Column 1 Column 2 Column i Column 2 

## Step 2: Figureyourtotal gallonageforthe month Gascl,ne ard Gasol,ne and specialfuel Otl'erfuels spec,al fuel Otl'erfuels 

### 1 Enter your actual (stick) inventory at the beginning of the month.This

amount must agree with closing inventory of preceding month"s return. 

### 1 2 Enterthe numberof invoiced gallons produced, acquired, received or

transported into Illinois during the month a Tax/fee-free invoiced gallons (Ser A. SA,"' DA, Ccbmr 1: Sch. LA Columr21 

### 2a b Tax/Jee-paid invoiced gallons (Sct;edule E. SE. or LE (dyed diesel fuel). Column 1:o!her !J&ls. Sch LE. Column 2) 

### 2b 3 Add lines 1 through 2b and enterthe result in Line 3. Rememberto do

calculations within each column. 

### 3 4 Enteryour actual (stick) inventory at the end oft11e month. 4 5 Subtract Line 4 from Line 3 and enterthe result on Line 5. 

### 5 

## 'ep 3: Figure your nontaxable gallonage 6 Enter the numberof gallons sold exempt in Illinois

a to railroads for direct rail operation (Schejule LBJ 

### 6a /I/I/I/Ill/!/!/!/!/ Illflll 

### I/!!Ill !Iii! b to qualified air carriers 1Sc1•edu!e U3, kernse~e. Colum" 1 utherfuels. CDlumn 21 

### 6b c to qualified ships, barges, and vessels (Scl'edule LB) 

### 6c Ii!!!If! /!if II/Ii I/ IIll!//// Iii

II!Jill 7 Enter the numberof gallons sold and delivered outside of Illinois

!Sct1edule C. SC. DC, Column 1, SGhedule LC. Column 2) 

### 7 8 Enterthe number of gallons sold and distributed tax!fee-free lo licensed

receivers (Sc,,eduie D. SD. or DD. co·~nw 1, Scl1ejuie LO Colum~2) 8 9 Enterthe number of gallons ot yourloss due io temperature variation or evaporation



### oryour gain due to temperature variation. Complete Line 9aor9b per column. a Loss. The amount of losses you claim are limited. See Instructions. 

### 9a 

## or 9b ( 

### I ( 

### I I I I b Gain. 10 Add Lines 6athrough 9b and enterthe result on Line 10. This is your total nontaxable gallonage. 

### 10 

## Step 4: Figureyourgrosstaxable gallonage 11 Subtract Line 1Ofrom Line 5 and enterthe result on Line 11. This is your gross taxable gallonage. 11 

## Step 5: Figureyour nettaxable gallonage 12 Enterthe number of gallons on which tax/fee was paid atthe time of purchase.12 13 Subract Line 12 from Line 11 and enterthe result on Line 13. 

### 13 14Add Line 13, Column 1 and Line 13, Column 2. This 1s your net taxable gallonage. 

### 14
______ _

,c·sfc,r"1 ,s a~:~o, ,ed as ~o'l,oe~ vr.1ar +~ ta< er<c,e Ac, ,rcp~s,nJ to~ ,~,erfee br 1·:h·ch t•, s fo
..**~** :s f·l~d. O,sdcswec• 11, ; •rlormalon ,s req·.J,red. RMFT-5-US-r. Page t <R-C-G 15) Fa'Jreto no·,:de ,c,fonn~:,ao ma,· rosu·, 10 this fO•m nat t>e•ng procEs$ed a~1 'lla;, result ,n**~** r;;,,M'l1• 

### I

## Form RMFT-5-US-X Page 2 Step 6: Figureyourtax and fee As originally reported or adjusted 15 Figure your gross lax and lee due. If the amount of Line 14 is greaterthan zero, ontortho amount from Line 14on the line provided below and multiply by tile tax and lee rates provided. Otherwise, enter "ff' in Lines 1Sa. 1Sb, and I Sc. a For underground storage tank tax: X 0.003. 

### 15a$.
_____ _ b For environmental impact fee:
______ X 0.008. L·oe'4.Co: 2 15bS
_____ _ c Add Lines 15a and 15b.This 1s your gross tax and fee due. 15c $.
______ _ 16 

### If you originally filed and paid your tax and fee due on time. figure your collection discount. See instructions. 16 $.
______ _ 17 Subtract Line 16from Line 1Sc and enterthe result on Line 17. This is yourtax and fee due. 

## Step 7: Figurethe amount you owe 18 Enterthe amountof credit you wish to apply. (See instructions.) 19 Subtract Line 18 from line 17 and enterthe result on Line 19.This is the tax/fee due. 

### 17S
18S
_____ _ 19S,
_____ _ 

## Corrected amounts
$ 

## s 

# s s s
s s 20 Total amount paid to date for tl1is reporting period. 

### 20s
______ _ 21 

### Jf Corrected Amounts Column. Line 19 is greaterthan Line 20, subtract Line 20from Line 19. This is the 

### amountyou owe. Make yourcheck payable to '"Hlinois Department of Revenue.'" 22 If Corrected Amounts Column. line 19 is less than Line 20, subtract Line 19 from Line 20. If you are claiming a credit, you must complete Step 9. 

## Step 8: Sign and dateyour amended return 21$
_____ _
22 S 

## I

Underpenalties of perjury, I state that l have examined ihis return and. to the best of my knowledge. it is true, correct, and complete. (
Signature or pe,sor, o11'er tl1an taxpayer. v,ro prepare:J tr.is ,e1urr 

### Dme Taxpa)'er"s rama Preparer's phono, rumber SogPature and 11tle oltaspayer 

### Mail this return andpaymentto: lflinois Department ofRevenue, PO Box 19019. Springfield. IL 62794-9019 

## Step 9: Complete your claim for credit Complete Lines 23 through 25 if you are claiming a credit. 

### 23 Explain below why the amountfor which the claim is filed is alleged to be a mistake offact oran error in law. Attach additional sheets ifyou need more space to write in. 24 Are you a partyto any civil suits involving the above amounts?
__yes no If yes. what is the name ofthe suit?
_______________ _ 25 Sign below s,giatureofda,:nnnt Title (State v,Piilher owrer. part~er. er authorized ager!) Dme

## I

( FORM 002



# <11 Illinois Department of Revenue



# \)~!:,~ 10 

# Salesand Use!~;,;,~,~ E911 SurchargeReturn REV 05 

### E S NS 

### __./

### __ CA RC

rm ST-1 is due on orbeforethe 20th day ofthe month following the end ofthe reporting period. You must round yourfiguresto wholedollars. (See instructions.} 

## Step 1:Alcoholic Liquor Purchases (See instructions.} 

## Step 5:Tax on Purchases If you are not required to report your purchases, go to Step 2. General merchandise Note: 01stnbutors will also report your total purcl1ases to us. A Total dollar amount of alcoholic liquor purchased {invo:ced and del•vered)

## -----1-- Step 2: Taxable Receipts 1 Total receipts (Include lax.) _____1
__ 2 Deductions - include tax collected (From Schedule A. line29.) 2 

# ______, 

# __ 3 Taxable receipts {Subtract line2 from Line 1.) 

## Step 3:Tax on Receipts Sales from locations within fllinois General merchandise 

### 3

4a 

### I x __ =4b
_____ _

. 1rat,;1 Food, drugs a11d medrcal appliances 

### 5a x =Sb (W1Cl

------ 

### Sales from locations outside Illinois General merchandise 

# ,, ------- x .0625 :::6b

------ Food, drugs and medical appliances 

### I
__ 

## 1_ 

# ' , 

# __ 12,
_____

### l
__

### x .0625 =i2b
_____

### 1
__ Food. drugs. and med,cal appliances 

### 13a 

## i
__x .01 Purchases at other rates 14,
______1
__ 

### 15 Tax due on purcl1ases (Add Lines 12tl. 13b. and 14b.) 

## Step 6: NetTax Due 16 Tax due trom receipts and purchases (Add Lines 11 and 15.) 16a Manufacture(s Purchase Cred11 (See instructions.) 

# 17 Prepa;d sales tax (Attach PST-2 copy A.) 

# 18 Quarter-monlhly payments {Paid on Form RR-3 or by EFT) 

# 19 Total prepayments (Add Lines 16a, 17. and 18.) 

### 20 Net tax due (Subtrac\ Line 19 from Lme 16.) 

### =13b
_____1
__ 14b,
_____1
__ 

### 15
______1
__ 

# 16 1- 

# 16, 1_ 

# 17 1- 

# 18 1_ 

# 19 1_ 20 

## 1_**~** 

### x .01 0 7b
_____

## 1__ Step 7: Payment Due Sales at prior rates Receipts taxed al other rates 

# ,, ' 9 Tax due on receipts (Add Lines4b, Sb, 6b, 7b. and Sb.) 8b
_____1
__ 

### 9 

## -----1-- Step4: Retailer's Discount and NetTax on Receipts 10 II you filed and paid by the due date. multiply Line 9 by 1.75% (.0175). 10 J
__ 11 Net tax due on receipts 

# ,-~(:S:c~bt:":':'~'':":'~1~0~tc~om:'.L~ic:e~9:.}'.....
__ ....'.1~1-=====:;-I-- @."""'. s~vices tax.illinois.gov 

## Try filing electronically!



# sT ..1{R·09 15) Usethisform only if a preprinted form is not available. Owner's name Business name ------------------- 

### 21 E911 Surcharge (From Schedule B. Line 10.) 

### 21 

## -----1-- 22 Excess tax and excess surcharge collected (See instructions.) 

### 22 

## ------1-- 23 Total 

### tax and surcharge due (Add Lines 20, 21 and 22.) 

### 24 Cred11 amount (See instructions.) 

# -+ 23 

## -----1-- 24
_____1
__ 

### 25 Payment dlJe (Subtract Line 24 from Line 23.) 

# .+ 25 

## I-- Step 8: Sign Below Under penalties of oerJury, I state !hat I have examined this return and, to the bes1 of my knowledge, it 1s true and correct. The intonnalio11 in this return is taken lrom the records ofthe business tor whicl1 it 1s liled. 

### _!_!_ Taxpayer Pt,ore Date 

### _!_!_ Prnparer Pho~e Date

Mailing address

( Jiness address ------------------ Write your check and send yourpayment to ILLINOIS DEPARTMENT OF REVENUE RETAILERS' OCCUPATION TAX SPRINGFIELD IL 62796-0001 1111111111111111111111111111111!1111111111111Account ID: This form isfor: 

### Schedule A - Deductions j;i,.g_c;:tion 1:Taxes and miscellaneous deductions· lfno Section 1deductions,go

### to Section2.



### 1 Taxes collected on general merchandise sales and service 

### 1 2 Taxes collected on food, drugs, and medical appliances sales and service 

### 2 3 E911 surcharge collected 3 4 Resale • 4 

### 5 Interstate commerce o 

### 5 6 Manufacturing machinery and equipment (including photoprocessing) 

### 7 Farm machinery and equipment 

### 8 Graphic arts machinery and equipment (Expired August 

### 30,2014) 9 Supplemental Nutrition Assistance Program (SNAP - formerly called food stamps} 

### 1 0 Enterprise zone 

### a Sales of building materials 

### b Sales oi 1iems otherthan building materials 

### 11 High impact business 

### a Sales of building materials 

### b Sales of items otherthan building materials 

### 12 River edge redevelopment zone building materials 

### 13 Exempt organizalions 

### 14 Sales of service - identify here --------- 

### 15 Other (including cash refunds. newspapers and magazines. etc.) - identify below 16 Total Section 1 deductions. Add Lines 1through 15. 

### Section 2: 

### Motorfuel deductions - If

### no Section 2 

### deductions, 

### go toSection 3, 

### State motorfuel tax Number ofgallons 17 Gasoline 17a x 18 Gasohol and majority blended ethanol 1

### Sa x 19 Diesel {including biodiesel and biodiesel blends) 19a x 20 Dieselhol 20a x 21 Otherspecial fuels 21a x 

### Rate 19c 19c 21.5C = 2"1.5c

19c 

### • 6 

### • 7 • 8 • 9

., 10a " 10b



### .. 11a • 11b • 12 

### • 13 14 15 16

17b 1Bb 19b 20b 21b 

### Specific fuels sales tax exemption Receipts Percentage 22 Gasohol 22a
_____f
__x 20% (.20) 

### = 22b 23 Biodiesel blend (90 -99 percent petroleum-basej product) 23a
______ f
__x 20°··~ (.20) = 23b 24 Biodiesel blend (1- 89 psrcen1 petroleum-based prcct~ct) 24a
______ f
__x 100% (1.00) = 24b 25 100percentbiodiesel 25a
______f
__x 100%(1.00)= 25b 26 Majority blended ethanol fuel 26a
______f
__x 100°,,o (1.00)"' 26b 27 Otller motor fuel deductions_______________ 27 28 Total Seciion 2 deduciions. Add Lines 17b through 26b and 27. 28 

### Section 3:Total deductions 29 Add lines 16 and 28. Write this amount on Step 2, Line 2 on the front page of this return. 

# ..+ 29 

### Schedule B - E911 

### Surcharge Receipts from retail transactions of prepaid wireless telecommunications service 1 Enter receipts subjectto E911 Surcharge. 1 

### Figure your breakdown of retail transactions for .Chicago locations 2 For Chicago locations 2a 

## 1--'
__ = 2b 

### 3b 3 For Chicago locations at prior rates 

### 3a
_____j
__, __ 4 Total E911 Surcharge for Chicago. Add Lines 2b and 3b. 

### Figure your breakdown of retail transactions for non-Chicago locations 5 For non-Chicago locations 5a 

### j
__, __ 6 For non-Chicago locations at prior rates 6a
______ f
__, __ 7 Total E911 Surcharge for non-Chicago locations. Add Lines Sb and 6b. 

### Figure your net E911 Surcharge 8 Total E911 Surcharge. Add Lines 4 and 7. 9 II you filed and paid by the due date, multiply Line 8 by 3% (.03). 10 Subtract Line 9 from Line 8. Write this amount on Step 7, Line 21. 

### 4 5b 6b



### 7 

### 8 9

### ~ 10 This ta•01 1s a,.1'1cr,,cJ asooll ~cd ucO~· th~ la< a• ice Ast ·n-μos,no 1r& tar. or •t~•er "'':Ch \".S •arm ,slri<;J. D-,cb"·~ ct lti s '".,wr,m:,r, cs ST-1 back (R-09'15) r~~s.r~O Fadum •aw,,,,u~ ,n!orf'1at-on C13/ 'ess·1 ,n l~s ;orM nor be1•11 v~cessed and trO)' ,es" t,n a ~analty ____ f
__

## l

_____ f
__

_____ f
__

_____j
__

_____ f
__ 

# ______; __

_____ f
__

_____ f
__ _f_

_____ f
__

_____ f
__

_____ f
__

_____ f
__

_____ f
__



### _____j
__

_____j
__

_____j
__

_____j
__

_____f
__

_____f
__

_____f
__



## ____f_(

_____f
__

_____f
__

____f
__

_____ f
__

_____ f
__

_____ f
__

_____ f
__

_____ f
__

_____ f
__

_____ f
__

_____ f
__

_ ____ f
__

_____ f
__

_____f
__

____f
__

_____f
__



### ____j_(

___f
__ 

## ----1- 

# ili!!illll!llll!illl!liil!llilllllllllllll

# c!J lsllin;_D 

# 1 epartmentof Revenue 

# \j 1- 

# Instructions General Information Who mustfile Form ST-1? You must file Form ST-1. Sales and UseTax and E91 I Surcharge Return, if you are making retail sales of any of the following in Illinois: • general merchandise, • qualifying foods. drugs, and medical appliances, andlor • prepaid wireless telecommunications service. "Genera! merchandise·' includes sales of most tangible personal property including sales of • soft drinks and candy; • preparedfood such as food purchased at a restaurant; • photo processing (getting pictures developed); • prewntten and "canned"computer software; • prepaid telephone calling cards and other prepaid telephone

calling arrangements; • repair parts and oiher items transferred orsold in conjunction

with providing a service under certain circumstances based on the actual selling price; and • grooming and hygiene products. See 86 Illinois Administrative Code regulations for a full listing of general merchandise. "Qualifying food, drugs, and medical appliances" include • food that has not been prepared for immediate consumption, ( such as most food sold at grocery stores. excluding hot foods. alcoholic beverages. candy, and sofi drinks; • prescription medicines and nonprescription items claimed

to have medicinal value, such as aspirin, cough medicine. and medicated hand lotlon, excluding grooming and hygiene products: and • prescription and nonprescription medical appliances that

directly replace a malfunctioning part ofthe human body. such as corrective eyewear, contact lenses, prostheses. insulin syringes. and dentures. See 86 Illinois Adminisirative Code regulaiions for a tull l1sting of qualifying food, drugs, and medical appliances. "Prepaid wireless telecommunications service" includes sales of • prepaid telephone calling cards and other prepaid telephone

calling arrangements. and • the minutes for ·'pay-as"you-go'" phones. 

### When 

### must Ifile 

### my return? You mustfile this return, along with any payment you owe. on or before the 20th day of the month following the end of your reporting period. The department determines how often you mustfile a return based on your initial registration and annual liability. Filing requirements based on your average monthly liability are determined as follows:

!Iyour average monthly liability is

• greaterthan $200, the department may notifyyou that your

filing frequency has been changed to a monthly requirement. • between $50 and $200, the department may notifyyou

that yourfiling frequency has been changed to a quarterly requirement. ST·l lrastruct,or.s IR·OS/15) • less than $50, the department may notify you that your liling frequency has been changed to an annual requirement. Note: !fthe due date falls on a weekend or holiday, your return and payment is due the next business day. 

### Can Ifile this return and pay thetax due electronically? Yes. you can use MyTax Illinois on ourwebsite at tax.illinois.gov to file \tour Form ST-1. MyTax Illinois also allows for electronic payment of any tax due. You can also file Form ST"1 using a direct file service through an outside vendor. 

### What 

## if I have multiple sites? ll you have one business but sell items at more than one location (site), you must collect and remit sales and usetaxes according to the rates of each particular location.You must complete and attach Form ST·2, Multiple Site Form, to your Form ST·1to show the breakdown oftaxes collected and paid irom each site. MyTax Illinois allows users to calcula1e theirtax due for each location on Form ST-2. Multiple Site Form, and combine their liability on a single Form ST·1. 

### Howcan Ifind outwhattax and surcharge rates I should be collecting? If you file electronically using MyTax Illinois, the rates will be populatedfor you accordingto your registration.You can also use the Tax Rate Database on ourwebsite attax.illinois,gov to look up location specific tax rates. Oep1;;nding upon the location of the sale, the actual sales tax rate may be higher than the state rate of 6.25 percent (1.00 percent for qualifying food. drugs, and medical appliances} because of home rule. non-home rule, water commission, mass transit, park district, county public safety, public facilities ortransportation, and county school facilitytax.The E911 Surcharge has two different rates, one for Chicago locaiions and onefor non-Chicago locations. These rates can also be found on theTax Rate Database on our website. 

### What

### if I add ordiscontinue one of my sites or change locations? MyTax Illinois allows users to correct, add, or delete their location information.You also can contact us by calling 217 785-3707 orwriting to: CENTRAL REGISTRATION DIVISION ILLINOIS DEPARTMENT OF REVENUE PO BOX 19030 SPRINGFIELD IL62794-9030 

### It is importantto keep your registration information updated so your returns will include the correct tax rates. 

### What 

### if I need help? II you need help, call us at 1 800 732·8866 or217 782-3336, call ourTDD-telecommunications device for the deaf at 1 800 544-5304, orvisit ourwebsite at tax.illinois.gov. Page1of6

# Specific Instructions When completing this form, please round to the nearest dollar by dropping amounts of less than 50 cents and increasing amounts of 50 cents or more to the next higher dollar. 

### Step 1: Alcoholic 

## liquor Purchases line

### A,Total dollaramount ofalcoholic liquor purchased (invoiced and delivered) - It you are a liquorstore, tavern, or a restaurant that ,;;ells alcohol and you are not required to remit quarter-monthly payments, you must report the total dollar amount of all alcoholic liquor invoiced and delivered during ihe lrabiliiy period, regardless of when you actually remit payment to your distributor. 

### By the 10th day of each month. e!;lch of \.'OUr distributors should give you a statement that identifies the total amount purchased during the previous month.This statement may be a summaryfor the month on the bottom of each of your invoices

### or on a separate report. Note: Liquordistributors will reportto us the value of alcoholic beverages invoiced and delivered to eacl1 retailerthe previous momh. ll you are not required to report yourpurchases. go to Step 2. 

### Step2:Taxable Receipts line 1 - Writethe amount you received from all sales of merchandise and service. including service charges. E911 Surcharge and taxes collected. Do not include purchases of merchandise on which you are paying usetax in Step 5. Note: You must include the county motorfuel tax imposed in DuPage, Kane, and McHenry counties in Line 1. line 2 - Write the mtal amount of deductions from Line 29 of Schedule A located on the back of Form ST·t.The amount of deductions on Line 2 cannot be more than the total receipts you wrote on Line 1. If so, you must file a claim !or credit on Form ST-1-X. Amended Sales and Use Tax and E911 Surcharge Return, lor the month you originally reported the sale. Line 3 - Subtract Line 2 from Line 1. 

### Step 

## 3:Tax 

## on Receipts If you reportfor multiple sites, you must use Form ST"2, Multiple Site Form. Sales froJTILocAtiot1s within Hlinois Note: If you are a multiple site retailer or serviceperson who also has out-oi-state locations. see the instructions for Lines 6a and 7a. Line 4a • General merchandise base Write the portion of line 3 that you received from sales of general merchandise, plus the amount you received from the general merchandise you sold in performing your service. Line 4b - Multiply Line 4a by the tax rate. Line 5a - Food, drugs, and medical appliances base Writethe portion of Line 3 that you received from yoursales of qualifying food, drugs, and medical appliances, plus the amount you received from the qualifying food, drugs, and medical appliances you sold in performing your service. line5b - Multiply Line Sa bythe tax rate.

ST-1 IPstrui;t1o~s (R-09115) SalesJ'mmiocafums outside Illinois Line 6a - General merchandise base ( Write the portion of line 3 that you received from general merchandise you sold to users in Illinois, plus the amount you received from general merchandise you sold for use in Illinois in performing yourservice. Line 6b - Multiply Line 6a by the tax rate. Line 7a**~** Food, drugs, and medical appliances base Write the portion of Line 

### 3 that you received from qualifying food, drugs, and medical appliances you sold to users in Illinois, plusthe amount you received from qualifying food. drugs, and medical appliances you sold lor use in lll1no1s 1n pertorming your service. Line

### 7b• Multiply Line 7a by the tax rate. Sal~tprior ratas Line Sa**~** Receipts taxed atother rates base Write on this line only the receipts from sales of merchandise and service you made at rates differentfrom the rates printed in Lines 4a, 5a, 6a, and 7a. lf you need instructions on how to report receipts from current sales that you believe are taxable at a different rate, call us at one of the numbers listed in the "What if I need helpTsection on the general information page. Line Sb - Multiply each amount 1n line Ba by the correct tax rate. add the results, and write the total on Line Sb. Note: Check your math. Lines 4a 

### + 5a 

### + 6a 

### + 7a 

### + Ba must equal Line 3. Line 9 · Add Lines 4b. 5b, 6b. 7b. and Sb. 

### Step 4: Retailer's Discountand NetTax on Receipts Line 1 O - II this return is electronicallyfiled, postmarked, or delivered and the tax is paid bythe due date, you are entitled to a discount. Multiply Line 9 by the percentage printed in Line 10. Line 11 - Subtract Line 10 from Line 9. 

### Step 5:Tax on Purchases Note: The figures you write on Lines 12a, 13a, and 14ashould not include amounts alreadycontained in Lines 4athrough Ba. Do not include tax in these Imes_ Line 12a - General merchandise base Write the sum of • yourcost of the general merchandise you purchased to use

from an out·of·state retailer who did not collect Illinois tax from you, • your cost of general merchandise you purchased tax free to

sell at retail, but instead used or consumed it yourself, • your cost of general merchandise you purchasedtax free to

sell in performing yourservice, but instead used orconsumed it yourself, ortransferred subject to use tax, and • your cost of general merchandise an out-of-state

serviceperson used in performing a service foryou, 

### if Illinois lax was not paid. Line 12b - Multiply Line 12a by the tax rate. Page2ol6 

### (

### (



## (

( Line 13a - Food, drugs, and medical appliances base \/,/rite the sum of • your cost ofthe qual1fy1ng food, drugs, and medical appliances

you purchased to use from an out-of-state retailer who did not collect Illinois tax from you, • your cost ofthe qualifying food, drugs, and medical appliances

you purchased tax free to sell at retail, bu! instead used or consumed it yourself. • your cost of the qualifying food. drugs, and medical appliances

you purchased tax free to sell in performing yourservice, but instead used or consumed it yourself, ortransferred subject to use tax. and • your cost of the qualifying food, drugs, and medical appliances an

out-of-state serviceperson used in petiorming a service for you, if Illinois tax was not paid. Line 13b• Multiply Line 13a by the tax rate. Line 14a - Purchases taxed at other rates base Write the total of all purchases you made

### at rates differentfrom the rates printed in Lines 12aand 13a.This includes • your costof the general merchandise and qualifying food, drugs,

and medical appliances on which you paid tax to another state at a rate lowerthan Illinois tax rates, and • your cost of the general merchandise and qualifying food, drugs.

and medical appliances an out-of-state serviceperson used in performing a service for you. ii Illinois taxwas not paid. line 14b - Multiply each amount in Line 14a bythe correct rate. add the results, and write the total 

### on Line 14b. Line 15 - Add Lines 12b, 13b, and 14b. 

### Step 6: Net tax due Line 16 -Add Lines 11 and 15. Line 16a• Write the total amountof Manufacturer's Purchase Credit (MPC) thatyou are using.This amount should include any MPC you have received from your customers plus any MPG of your ownthat you are using to satisfy use tax on qualif}1ing purchases forthecurrent liability period. Line 17- Complete Ltre 17 only ifyou prepay Illinois sales tax on motor tuel.Write the amount ol salestax you prepaid on motorfuel by adding the total from the PST-2, Prepaid SalesTax Statement ofTax Paid, forms you are attaching to this return. Line 18• Complete Line 18 only ifyou made quarter-monthly payments. Include on this line any prior overpayment credit that you used to makethese payments. Line 19 -Add Lines 16a, 17. and 18. Line 20 - Subtract Line 19 from Line 16.

ST·1 lns1ructions (R-09115) 

### Step 7: Payment due Line 21 Write the total amount ol E911 Surcharge tram Line 10 of Schedule B located on the back of Form ST-1. Line 

### 22 •ll you collected more tax or

### E911 Surcharge than is due, write yourtotal excess tax and excess surcharge collected. Line 

### 23

- Add Lines 20, 21 and 22. Line 24 • If you have a credit memorandum orprior overpayment and you wish to use it towards what you owe, write the amount you are using. Line

### 25 · Subtract Line 

### 24from Line 23.This is the amount of tax and E911 Surcharge that you owe. 

### Step 8: Sign below We cannot process this form until 

### it is signed bythe owner, officer, or other person authorized to sign the return. You owe a late-filing penalty 1f you do not file a processable return by the due date, a late-payment penalty ii you do not pay the amount you owe by the original due date of the return orwere required to make quarter-monthly payments and failed to do so, a 

### bad check penalty iiyour remittance is not honored by yourfinancial institution, and a cost of collection fee ifyou do not pay the amount you owe within 30 days ofthe date printed on a bill. For more information. see Publication 103, Penaltyand Interest for IllinoisTaxes. available on our website at tax.itlinois.gov. We will bill you for any penalty and interest amounts owed. Send your return and remittance to: ILUNOlS DEPARTMENT OF REVENUE RETAILERS' OCCUPATIONTAX SPRINGFIELD IL 62796-0001

Page3o!6

## Schedule A Instructions Total deductions claimed cannot be morethan thetotal receipts, including PrepaidWireless E911 Surcharge and tax, on Line 

### 1 ofthe ST-1 return. When completing this schedule, please round to the nearest dollar by dropping amounts of less than 50 cents and increasing amounts of 

### 50 cents or more to the next higherdollar. line 1•Taxes collected on general merchandise sales and 

### service Write the amount of tax you collected on your retail sales ofgeneral merchandise and tax you collected on general merchandise you sold 1n performing service_This includes food sold for immediate consumption, such as food sold at a restaurant. Line 2 •Taxes collected on food, drugs, and medical appliances sales and service Write the amount of tax you collected on your retail sales of qualifying food, drugs, and medical appliances and tax you collected on qualifying food, drugs. and medical appliances you sold in performing service. Line 

### 3 - E911 Surcharge collected Write the amountof E911 Surcharge you collected on your retail sales ofprepaid wireless telecommunications service. Line 4 - Resale VVrite the amount you collected from tl1e items you sold to someone who will resell those items at retail. For each salefor resale you make. the bu>•er must give you an Illinois certificate 

### of resale or have a blanket certificate of resale on file with you. Line 

### 5 - Interstate commerce Write the amount you collected from merchandise you sold that was shipped or delivered by you outside Illinois. Line 

### 6 - Manufacturing machinery and equipment (including photoprocessing) Write the amountyou collected from the sale of qualifying machinery and equipment (including repair and replacement parts) that produce iiems io be sold. Line 7 - Farm machinery and equipment Writethe amountyou collected from qualifying farm machinery and equipment (including repair and replacement parts) you sold for use in production agriculture. Line 

### 8 - Graphic arts machinery and equipment Write the amount you collected from qualifying graphic arts machinery and equipment (including repair and replacement parts). Note: This exemption expired August 30, 2014. Line 

### 9 - Supplemental Nutrition Assistance Program (SNAP - formerly called food stamps) Write the amount you collected from customers who used SNAP beneiits.

ST-1 ln51ructions (R-09/151 Line 1 O**~** Enterprise zone a) Sales of building materials ( Write the amountyou collected from sales of building materials to a customer who will incorporate those materials into an enterprise zone certilied by the Illinois Department of Commerce and Economic Opportunity (DCEO). You must maintain in your books and records the documentation obtained from the customer and required by the department's rules to supportthe exemption. 

### b) Sales of items other than building materials Write the amount you collected irom sales of items other than building materials

### to a business certified by DCEO to buy consumables tax free. You must maintain in your books and records the documentation obtained from ihe customer and required by the department's rules to support the exemption. This amount can include, but is not limited

### to:

tangible personal property used orconsumed in the operation of pollution control facilities. tangible personal property used orconsumed within an enterprise zone 1n the process of manufacturing or assembly oftangible personal property tor wholesale or retail sale or lease. tangible personal property used orconsumed within an enterprise zone in the process of graphic arts production 

### 11 used or consumed 

### at a certified facility. including repair and replacement machinery and equipment used in the operation ofa high ( impact service facility within the enterprise zone. jetfuel used in the operation of high impactservicefacilities. machineryand equipment used in the operation of an aircraft maintenancefacility locatedwithin an enterprise zone. Line 11 - High Impact Business a) Sales of building materials Write the amount you collected from sales of building materials to a customerwho will incorporate those materials into a high impact business location certified by the DCEO. b) Sales of items otherthan building materials Write the amount you collected from sales of items other than building materials

### to a business certified by DCEO as a high impact business. This amountcan include, but is not limitedto, tangible personal property used orconsumed:

by a high impact business in the process of manufacturing orassembly of tangible personal propertyfor wholesale or retail sale or lease. by a high impact business in the process of graphic arts production 

### ii used or consumed at a certified facility. including repair and replacement. Line 12 - River edge redevelopmentzone building materials Write the amount you collected from sales of building materials to a customerwho will incorporate the materials into real estate within a River Edge Redevelopment Zone 1n accordance ( with the Act by remodeling, rehabilitating, oradding new construction. Page4of6Line 

### 13• Exempt organizations Write the amount you collected Imm merchandise you sold to organizations that are exempt from paying sales tax. For each tax- ( exempt saleyou make. you must obtain a copy of the organization's Illinois SalesTax exemption idenlificat1on number.



## ( Note: Do not include motorfuel taxes reported on Line 15 or Section 2. Line 14- Safes of service Write the total of any portion of all service transactions on which you did not charge your customers tax. Identify on ihe line provided the type oftransaction thattook place. Some examples of these are transactions made by dry cleaners, hairdressers, medical professionals, pharmacists, and other servicepersons. Line 15• Other Identify other deductions.\\'rite the amountyou collected from the sale of the deductions you listed. This amount can include: cash refunds - write the amount ol cash reiunds you made to customers for merchandise they returned and on which you have paid tax to us during the preceding return period or have now included on Line 1of your Form ST-1. Note: This amount should not include the tax amount from 1he returned item. newspaperand magazine sales - write the amount you collected from yoursales of newspapers. magazines, and other periodicals. proceeds of mandatory service charges separately stated on customers" bills for purchase and consumption of load and beverages, to the extentthat the proceeds ofthe service charge are in fact turned over as tips or as a substitute fortips to employees who participate directly in preparing, seNing. hosting. orcleaning up the food or beverage function with respect to which the service charge is imposed. other deductions allowed in the Acts not listed on Lines 1 through i4or Section 2.

ST·1 lnslruct,o,~s (R·09.'15) Line 16 -Total taxes and miscellaneous deductions Add the amounts on Lines i through 15, and write the total. Lines i 7through 21 - State motorfuel tax For each type of fuel, write the number of gallons you sold. Multiply the number of gallons bythe state tax rate printed on Lines 17through 21 of Schedule A. and write the total for each type of fuel. Note: The county motorfuel tax imposed in DuPage, Kane, and McHenry counties must be included in the gross receipts on Line 1 ofyour return.These taxes are not authorized deductions from your gross receipts. Report any other local motorfuel taxes on Line 15. '"Other.'" Do not include ihem on Lines 17"21. Lines 22 through 27 - Speclficfuels sales tax exemptions Subtract all motorfuel taxes and all state and local sales laxes from the amount you received for the specific fuel types listed. Multipi)'your receipts for each type of fuel by its corresponding rate on Schedule A, and write the total for each type of fuel. Note: On Lines 22 and 23, do not include receipts from sales that are not subjectto sales tax. Line 28 -Total motorfuel deductions Add the amounts on Lines 17b through 26b and 27. and write the total. Line 29-Total deductions Add the amounts on Lines 16 and 28, andwrite this amount on Line 29 and on Step 2. Line 2 of Form ST-1. Note: This amount cannot exceed the amount reported on Line 1 ofyour ST-1 return.

Page5of6

## Schedule B Instructions Wl1en completing this schedule, please round to the nearest dollar by dropping amounts of less than 50 cents and increasing amounts of 50 cents or more lo the next higher dollar. Line 1•Write the total receipts from retail transactions of prepaid wireless telecommunications service. Note: Do not complete Schedule Bin ihe same mannerthat you complete Step 2 of Form ST-1. Instead Line 1 ofSchedule B should only report your receipts subject to the E911 surcharge, not all amounts collected for the reporting penod. Do no; include receipts from sales that are exempt from the E911 surcharge.Also do not include the amount of surcharge you actuallycollected from your customers. .Ei.g_u@_j[our b@ilkdown olf(lliiil transactions for Chicago locations Locations within the city limitsof Chicago are considered Chicago locationstor purposes of E911 Surcharge collections. Line2a •Write the portion oi Line 1 receipts that were collected from retail transactions of prepaid wireless telecommunications service at Chicago locations. Line 2b • Multiply Line 2a by the surcharge rate of 9 percent (.09) for Chicago locations. Line 3a • Writethe portion of line 1 receipts that were collected from retail transactions of prepaid wireless telecommunicat1ons service at Chicago locations at rates differentfrom the Chicago locations included on Line 2a.This linewill only be used if a rate change should occur and you are remitting E911 Surcharge for receipts that were subjectto the rate priorto the change. Line 3b • Multiply line 3a by the surcharge rate. Note: Priorto October 1, 2014. the Prepaid Wireless E911 Surcharge fo1· Chicago locations was 7 percent (.07). The rate increase bringing the E911 Surcharge rate to 9 percent forthe city of Chicago is only effective through June 30, 2017. On July 1. 2017. the E911 Surcharge rate for the city of Chicago is scheduled to revert back to 7 percent. Line 4 • Add Lines 2b and 3b.

ST-1 lrs!ructions (R·09!151 El.g_ure your breakdown of retail ti:ansactions for D...Qn-Chicag.9 locations ( LineSa·Write the portion of L1r.e 1 receipts that were collected from retail transactions ol prepaid wireless telecommunications service at non-Chicago locations. Line Sb

- Multiply Line Saby the surcharge rate of 

### 3 percent 

### (.03) for non-Chicago locations. Line 6a • Write the portion of Line 1 receipis thatwere collected from retail transactions of prepaid wireless tetecommurncati::ins service at non-Chicago locationsat rates dlfferenl from the non-Chicago locations included on Line Sa. This linewill only be used if a rate change should occur andyou are remitting E911 Surcharge for receipts that were subject to the rate prior to !he change. line 6b • Multiply Line 6a by the surcharge rate. Note: Priorto October I, 2015. the Prepaid Wireless E9t 1 Surcharge for non-Chicago locations was 1.5 percent (.015). Line 7 • Add Lines Sb and 6b. Line 8 • Add Lines 4 and 7. line 9 • If Form ST-1 is electronically filed, postmarked, or delivered and the surcharge is paid by the due date, you are entitled to a discount. Multiply line 8 by the perceniage printed in Line 9. Line 10• Subtract Line 9 from Line 8 and write this amount on Line 1 0 and on Step 7. Line 21 of Form ST-1.

Page 6 o! ii 

## (

(

## Illinois Department of Revenue 

# ST-1-X Amended Sales and UseTax and E911 Surcharge Return

General Information Everyone must complete Steps 1. 

### 2. 4. and 

### 5. You must also complete Step 3 ifyou believe thatyou have overpaid. 

# Step 1: Identify your business. 1 AccountlD:
_______ _ REV 05 FORM 003 Staiion 820, 833 

### ES
__

### !_/
__ NS DP CA RC Do not write above thjs line. Amount you are paying:

### S
_____________ _ Make your check payable to "Illinois Department 

### of Revenue."



### 3 Business name:-------------- 

### 2 Reportingperiodyouareamending:_ /_ I
___througll_ ! _!
_____ _ Mort1' Day Year r.fontl' Day Year 

# Step 2: Markthe reason why you are filing an amended return. 1
__ Overpaid (Complete Step 3) 3
__ Response to notice or bill 

### 2
__ Underpaid 

### 4
__Corrections to line items but no additional tax due 

# Step 3: Markthe reason(s) whyyou have overpaid your return. Ifyou collected the overpaid tax orE911 Surcharge from yourcustomer(s), you musthave unconditionaJ/yrefunded the overpaidamountto yourcustomer(s) beforeyou file a claim forcredit.

_I am decreasing Line 1 orI am increasing Line 2 because I sold merchandise 

### a _loanother Illinois business for resale. List the account ID(s) on Schedule RE and attach to Form ST-1-X. b _to an out-al-state customer and ii was delivered to a location outside Illinois. 

### c _to an exempt organization. List the tax exempt (E) number(s) on Schedule RE and attach to Form ST-1-X. d _that qualifies for atax exemption for machinery or equipment used in manufacturing, !arming. or graphic arts. (Note:The graphic arts machinery and equipment exemption expired August 

### 30, 2014) 

### e _ihat qualifiesfor an enterprise zone exemption. 

### I _thatwas returned 

### by my customer. 2 _I included receipts from prior month(s} or used the wrong month's receipts. 3 Ifailed to include tax collected in Line 2. 4 _I used the wrong tax rate. 

# Turn page to complete Steps 4 and5. 5 _Thetax base is correct but I put it on the wrong tax line. 6 _I made a math error calculating Lines 9,11,15. 20, 23, or 25. 

### 7_I failed to take the discount ormade 

### a math error calculating the discount. 8_I made errors completing Form ST-2. Multiple Site Form. 

### 9 _I am a retailer who is exchanging Manufacturer's Purchase Credit from a customerfor cash previously paid. 10_I overpaid use tax because Ifailed 

### to use Manufacturer's Purchase Credit to pa\.' use tax. 11 _I overpaid use tax because the item a _qualifies for a tax exemption for machinery or equipment

used in manufacturing, farming, or graphic arts. {Note:The graphic arts machinery and equipmentexemption expired August

### 30, 2014) b _qualities for an enterprise zone exemption. c _was shipped to and used at

### asite outside Illinois. d _was returned to my supplier.



## lill!li1'111111llillll1lllillll!llillllII!!llilllll

ST-1-X (R-09115) Th,s 1,wn ,s aul'>urz~j as oa'l:n~Q ,wfo, !~e taxu'fe~ Act ,fl'poc,.nJ 1t-,e,~,c,'~< b,,ch-Ch !h:S Ferm " 'led D•solosuce cl tl1:s ,c,for!'laMn IS ,equ.red F~,:~·e 10 prov,d~ .nbm,al :,n f"a/ ,esu•t inth:c. lo,m no< beo\3 p,ocessedMd r,,sy '"""'I :n a rena1 ty.

# Step 4: Correctyourfinancial information. Complete all applicable lines. Please round to the nearestwhole dollar. 

### Alcoholic Liquor Purchases

A Total dollaramount of alcoholic liquorpurchased (invoiced and delivered) 

### Taxable Receipts

1 Total receipts (Include tax.) 2 Deductions - include tax collected (From Schedule A-X, Line 29) 3 Taxable receipts (Subtract Line 2 from Line 1.) 

### Tax on Receipts Sales from locations within Illinois

4a General merchandise tax base 4b General merchandise tax - Multiply Une 4a byyourtax raie of
__ _ Sa Food, drugs. and medical appliances tax base Sb Food, drugs. and medical appliances tax - Multiply Line 5a by yourtax rate of
__ _ 

### Sales from locations outside tllinois

Sa General merchandise tax base 

### Sb General merchandise tax· Multiply Line 6a by 6.25 percent (.0625). 

### 7a Food. drugs, and medical appliances tax base 7b Food, drugs. and medical appliances tax - rv1ult1ply Line 7a by 1 percent (.01). 

### Sales at prior rates

Ba Receipts at other rates tax base 

### Sb Receipts at 01her rates tax - Multiply Line 

### 8a by the appropriate tax rate ol
__ _ 9 Tax due on receipts (Add Lines 4b, 5b. 6b, 7b, and Bb.) 

### Retailers' Discountand NetTax Due on Receipts 10 Discount (See instructions.) 11 Nettax due on receipts (Subtract Line 10 from Lme 9.) 

### Tax 

## on Purchases 12a General merchandise tax base 

### 12b General merchandisetax - Multiply Line 12a by 6.25 percent (.0625). 13a Food, drugs. and medical appliances tax base 13b Food. drugs. and medical appliances tax - Multiply line 13a by 1 percent (.01). 

### 14a Purchases at other rates tax base 

### 14b Purchases aiother rates tax - Multiply Line 14a by the appropriate 1ax 

### raie of
__ _ 

### 15 Tax due on purchases (Add Lines 12b, 13b, and 14b.) 

### NetTax Due 16 Tax due from receipts and purchases {Add Lines 11 and 15.) 

### 1Sa Manufacturer's Purchase Credit (See instructions.) 

### 17 Prepaid sales

### tax (See instructions.) 18 Quarter-monthly payments (Paid on Form RR-3 or by EFT) 

### 19 Total prepayments (Add Lines 16a, 17, and 18.) 20 t>let tax due (Subtract Line 19 from Line 16.) 

### Payment Due 21 E911 Surcharge (From Schedule 8-X. Line 10.) 

### 22 Excess tax and excess surcharge collected 

### 23 Total tax and surcharge due (Add Lines 

### 20, 21, and 22.) 

### 24 Credit amount (See instructions.) 

### 25 Subtract Line 24 lrom Line 23.This is the net total due. 

### 26 Enter !he total amount you have previously paid. Compare Line 25, Column 

### B. and Line 26. • If Line 26 is greaterthan Line 25, Column B. enterthe difference on Line 27. • If Line 26 is less than Line 25, Column B, enterthe difference on Line 28. 

### A 1 

### 2 3 

### 4a 4b 

## 5a Sb 

## Ga 6b 

## 7a 7b 

### Ba 

## Bb 9 

### 10 11 

### 12a 12b 

### 13a 13b 14a 14b 

### 15 

### 16 16a 17 18 19 

### 20 21 

### 22 

### 23 24 

### 25 

# Column A l~0s! re:er( f1~urn, t.le::J 

## 1_ A 

## 1_ 1 

## 1_ 2 

## 1- 3 

### 4a

____;_ 4b 

## ----1- 5a

____1_ 5b 

## ----1- Ga

___1_ 6b 

## ----1- 7a

____1_ 7b



## ___I_ Ba

___I_ Sb



## ____1_ 9



## ____1_ 10



## ____1_ 11



### ____:_12a

____i_12b



### ____l_13a

___l_13b 

### ----1-14a

_ ___l_14b



### ____1_15



### ____1_16

____1_16a

____1_17

____1_18

____1_19



### ____1_20

____1_21



### ____1_22 ----1-23



### ____1_24

____1_25 26


### 27 Overpayment -This is the amount you have overpaid, Go to Step

### 5 and sign this return. 

### 27 28 Underpayment - This is the amount you have underpaid. Please paythis amount. Enterthis amount on Page 

### 1. 28 Go to Step 5 and sign this return. Make your check payable to "lllinols Department of Revenue." 

# Column B Figures as tl'ey sl"%11 have teH1 f1lej 

## 1_1 1_ 

## I_ 1_

___1_ 

## ---1- ---1-

____1
_ 

## ---1- ---1-

___1_

____1_ 

## ---1- ---1-

____ 1
_



## ____1_ 

## ---1-

____1_



## ___1_

___1_

___1_ 

## ---1-{

___1_

___ 1
_



## ____1_



## ___1_

___1_ 

## ----1- 

## ---1- ---1-

____ 1
_



## ___1_

___ 1
__ 

## ---L. 

# --1-

___1_

___1_

___1_ 

# Step 5: Sign below. Under penalties of perjury, I state that I l1ave examined this return, and to the best of my knowledge, it is true, correct, and complete. Under penalties of perjury, 

### I state that 

### I have unconditionally refunded to mycustomer(s) any overpaid sales tax and E911 Surcharge that Icollected from my customer(s) and am claiming as an overpayment on this return. Taxpayer Phone Mail to: lLLINOIS DEPARTMENT OF REVENUE PO BOX 19034 SPRINGFIELD IL 62794-9034 ST+X (R-09/15) Date Preparer Phone Dale 

# lill:ltl!!ll!!!ll!lllil[liillill!lilllllillllllllAccount ID:
_______ _ Reporting periocl you are amending:
__.'
__'
____through
__ /_ 

### i
___ MortP Day Year Monlh Day Year 

### chedule A-X - Amended Deductions ColL1mn A l·,·1~s1 recent 1, urn5 hied 

### ciectian 1:Taxes and miscellaneous deductianEi - Ifno Section 1 deductions,gota Section 2.

1 Taxes collected on general merchandise sales and service 1 

### I 2 Taxes collected on food, drugs, and medical appliances sales and service 2 

### I 3 E911 surcharge collected 3 

## I 4 Resale • 4 

### I 5 Interstate commerce • 5 

### I 6 t,1anulacluring macl1inery and equipment (including photoprocessing) • 6 

### I 7 Farm machinery and equipment • 7 

### I 8 Graphic arts machinery and equipment (Expired August 30, 2014) • 8 

## I 9 Supplemental Nutritron Assistance Program (SNAP· formerly called food stamps) e 9 

### I 10 Enterprise zone a Sales of building materials b Sales of items other than building materials 11 High impact business a Sales of building materials b Sales of items other than building materials 12 River edge redevelopment zone building materials 13 Exempt organizations 14 Sales of service - identify here
_______ _ 15 Other (including cash refunds, newspapers and magazine, etc.)· identify below 16 Total Section 1 deductions.Add lines 1through 15. o 

### 10a 

### o10b

o 

### 11a 11 

### 11b 

### • 12 • 13

14 15 1
_ 

### 16 Section 2: 

### Motorfuel 

### deductions· If 

### no Section 2 

### deductions, goto Section 3. 

### State motor fuel tax 17 Gasoline - numberof gallons ( Multiply Line 17a by 19c (:19). 18 Gasohol and majority blended ethanol • number of gallons Multiply Line 18a by 19c (.19). 19 Diesel (including biodiesel and biodiesel blends) - number of gallons Multiply Line 19a by 21.Sc (.215). 20 Dieselhol • number of gallons Multiply Line 20a by 21.Sc (.215). 21 Other special fuels - number of gallons Multiply Line 21a by 19c (.19). 

### Specific_iy_ejs salestax exemption 22 Gasohol · total receipts Multiply Line 22a by 20°-o (.20). 23 Biodiesel blend (90 - 99 percent petroleum-based product) - total receipts Multiply Line 23a by 20°.-;, (.20). 24 BiodieseJ blend (1- 89 percent petroleum-based product) - total receipts Multiply Line 24a by 100% (1.00). 25 100 percent biodiesel · total receipts Multiply Line 25a by 100% (1.00). 26 Majority blended ethanol fuel - total receipts · Multiply Line 26a by 100",'o (1.00). 27 Other motorfuel deductions.
_____________ _ 26 Total Section 2 deductions. Add lines 17bthrough 26b and 27. 

### Section 3:Total deductions 29 Add Lines 16 and 28. Enterthese amounts on Step 4, Line 2.

# a+ 17a 17b 

### 18a 18b 19a 19b 20a 20b 

### 21a 21b 22a 22b 

### 23a 23b 24a 

### 24b 25a 25b 

### 26a 26b 27 28 29 

## -----1-- -----1-- -----1 -----1--·

____1
__

____ 1
__ 

## ----1-- ----1-- ----1--

____ 1
__

____1
__

____1
__

____ 1
__

____ 1
__

____ 1
__ 

## ----1--

____ 1
__

____1
__

____1
__

____ 1
__

____1
__

____1
__ Column S F,;presas li'e,' stio,,la lrnva beenhlea

_____1
__

____1
__

____ 1
__ 

## ----1-- ----1-- ----1-- ---~-1--

____1
__

____ 1
__

____ 1
__

____ 1
__

____ 1
__ 

## ----1-- ----1--

_____1
__

____1
__

____1
__

____ 1
__

____ 1
__

____1
__

____ 1
__

____1
__ 

## ---1- ----1-- ----1--

____ 1
__

____ 1
__

____ 1
__ 

## ----1-- ----1-- ----1-- ----1--

____1
__

____1
__



### ____ j
__ 

## ----1-- ----1--

____1
__

____1
__

_ ___1
__

_____1
__

11111111!1111!'11111111!111!11111:lll!llll!llmlllll ST·1·X (R-09/15)Account JD·
_______ _ Reporting period you are amending:_ ,' .'
____throuah
_ .'
__: ___ M~rth Day Y<aar M;:irr1, Dsy Yea, 

### Schedule B-X - Amended E911 Surcharge Column A M:s1 recerl frJJres !Ll<:d Column B 

## f.11o~l~'~.~:/'tC:/~~{1od Receipts from retail transactions of prepaid wireless telecommunications service

1 Enter receipts subjectto E911 Surcharge 

### 1 

# ___, 

# _______, 

# __ Figureyour breakdown of retail transactions for Chicago locations



### 2 For Chicago locations 

### 2a 

# , 

# _______, __ Multiply Line 2a by your surcharge rate of 

### 2b 

# ____

# ,__ , __ 3 For Chicago locations at prior rates 

### 3a 

# ____,_ 

# ·--'--

Multiply Line 3a by your surcharge rate of 

### 3b 

### ____

# ,__ , 

# __ 4 Tmal E911 Surcharge for Chicago. Add Lines 2b and 3b. 

### 4 

### ____

# ,__ , 

# __ Figure your breakdown of retail transactions for non-G.hiCMQ locations



### 5 For non-Chicago locations Sa 

# _____, 

### _______, 

# __ Multiply Line 5a by your surcharge rate of 

### Sb 

### ____

# ,__ , 

# __ 6 For non-Chicago locations at prior rates 

### 6a 

### ____

# ,__ , __ Multiply Line 6a by yoursurcharge 1·ate 

### ot 6b 

# ____

# ,__ , __ 7 Total E911 Surcharge for non-Chicago locations. Add Lines 5b and 6b. 

### 7 

# ____

# ,__ , 

# __ Figure your 

### net E911 Surcharge



### 8 Total E911 Surcl1arge. Add Lines 4 and 7. 

### 8 

# _____, _______

# , 

# __ 9 If you filed and paid by the due date. multiply Lme 8 by
.See instructions. 

### 9 10 Subtract Line 9 from Line 8. Enterthese amounts on Step 4. Line 21.

### ~ 10 

# ______

# , 

# ________, 

# __

______!
________, __



## (



# lillllllillilillllll!illll:llilllllllllilllll'IIIII ST-1-X (R-09/15)

# <J I, .ois Department of Revenue 

# Schedule C Attach to Form RMFT-5 or Form RMFT-5-US**~** 

# MFT, UST, 

# and EIF Sales andTransfers ofGasoline Products Delivered to Points Outside of Illinois Step 1: Complete the following information
Company name Vour license number
Name ofstate intowhich shipmentswere made Reporting period
__ /
___ _ Month Year 

## Step 2: Reportyour exported gallons 1 

### 2 

### 3 Invoice date Invoice Name of (month, day, year) number carrier 

### 1 __ ! _ _)
____ 

### 2 

### __)

### __ / 

### ____ 3 

# --'--'---- 4 

### __ { 

# __ / 

# ____ 5 __!
__!
____ 6 

### _ _) 

### __ { 

# ____ 7 

# --'--'---- 8 __ !
__ !
____ 

### 9 

# __{ 

### __ / 

### ____ 10 

# __{ 

# __ / 

# ____ 4 Bill oflading or manifest number 

### 5 Nameorpurchaser



### 11 Add the invoiced gallons in Column 8, Lines 1 through 10.Write the total amount here. 

### 6 Origin (Illinois cities only) 

### 7 Destination (city and state)



### 12 lfyou are filing only one Schedule C, write the amountform Line 11 here and on Forms RMFT-5 and RMFT-5-US, Line 7, Column 1. Ifyou arefiling more than one Schedule C, add Line 11 from each schedule, and write the total on Line 12 ofthe last page. Also write this amount on Forms RMFT-5 and RMFT-5-US, Line 7, Column 

### 1. 

## }~tu~'\~~rt~'~'.';~n~~~,;:IJ~~tl:~1lle:~?t~~C~";[~';1iJt1,~'7or~~~~"t,~l~l~'i:~~:~·t~'N1!"~~;~;i~~~;l~~1,'tc"Jn\~~lflforniallonIS

## ,c~~J~oi~:J RMFT-8front (R-02100) 

### Page
__of
__



### 8 Invoiced gallons



### 11
_____**~** 

### 12
_____ _

## General Instructions This schedule is used for reporting the following taxes: Motor Fuel Tax (MFT) Underground StorageTankTax (UST) Environmental Impact Fee (EJF) 

## Which gasoline products must be reported on this schedule? The gasoline productsthat must be reported on this schedule are all products commonly or commercially known orsold as gasoline {including casing-head and absorption or natural gasoline), gasohol, motor benzol, or motor benzene, regardless oftheir classification or use. 

## When do Ifile this schedule? You mustfile Schedule C in duplicate with Form RMFT-5 or, 

### ifyou are not a licensed distributor, with Form RMFT-5-US. 

## What records must I keep? You are required by lawto keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What 

## if I need additional assistance? lfyou have questions about this schedule, write to us at Motor FuelTax, Illinois Department ofRevenue, P.O. Box 

### 19477, Springfield, Illinois 

### 62794-9477, or call ourSpringfield office weekdays between 8 a.m. and 

### 4:30 p.m. at 

### 217 782-2291.

RMFT-8 back (!,..Q?IOO) 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, the state intowhich you made fuel sales or transfers, and the period for which you are reporting.You must prepare a separate schedule for each state. 

## Step 2: Reportyour exported gallons Lines 

### 1 through 

### 10

- Column 

### 1 - Write the month, day, and year ofthe invoice. Column 

### 2 - Writethe invoice number. Column 

### 3 - Write the carrier's complete business name. Column 

### 4 - Write the bill of lading or manifest number. Column 

### 5 -Write the purchaser's complete name. Column 

### 6 -Write the name ofthe Illinois city from which the gasoline product originated. Column 

### 7 -Write the name ofthe city and slate (using the two-character U.S. Post Office abbreviation) to which the gasoline product was delivered. Column 8 -Writethe numberof invoiced gallons.**~** 

### Line 

### 11 -Add the invoiced gallons reported in Column 

### 8, Lines 

### 1through 

### 10. Line 

### 12 - Ifyou arefiling only one Schedule 

### C, write the amountfrom Line 

### 11 on Line 

### 12 and on Forms RMFT-5 and RMFT-5-US, Line 

### 7, Column 

### 1. Ifyou are filing more than one Schedule C, add Line 

### 11 from each schedule, and write the total on Line 

### i 

### 2 ofthe last page. Also write this amount on Forms RMFT-5 and RMFT-5-US, Line 

### 7, Column 

### 1.



### t~

# <J - Iii...ois Department of Revenue 

# MFT, UST, 

# and EIF 

# Schedule D Gasoline Products Sold and DistributedTax- and Fee-Free in Illinoisto Licensed Distributorsand Receivers Attach lo Form RMFT-5 or Form RMFT-5-US 

## Step 1: Complete the following information Page~_of~_

Companyname Check the lax/fee type you are listing on this page. 

## O MFT-free only Your license number Reporting period

_ _ 

### !

_ __ _ Month Year 

## Step 2: Reportyourtax- andfee-free sales 1 Invoice date (month, day, year) 

### 1 

# _ _)



### __ / 

### ____ 2 

# _ _)



### __ / 

### ____ 3 __ !
__ ,____ 

### 4 

### __)

### __ / 

# ____ 5 

# _ _)

### __ / 

### ____ 6 

### __)

### __) 

# ____ 7 

# _ _/



# __

# , ____ 8 

# __

# , _

_)

### ____ 9 

# __ / 

# _

_)

# ____ 10 

## __ CJ
____ 2 Invoice number 

### 3 Nameof carrier 

### 4 Bill oflading or manifestnumber 

### 5 Name ofpurchaser 

### 6 Origin (lllinois cities only} 

## O UST-/E!F-free only 

## O Both MFT- and UST-/EIF-free



### 7 Destination (Illinois cities only) 

### 8 Purchaser's license number



### 11 Add the invoiced gallons in Column 9, Lines 1through 10, and write the total here. 11 12 Ifyou are filing only one Schedule D, write the amountfrom Line 11 here. 12 Ifyou are reporting MFT-free gallons only, also write this amount on Form RMFT-5, Line Sa, Column 1. • UST- and EIF-free gallons only, also write this amount on Form RMFT-5-US, Line 8, Column 1. • both MFT- and UST-/ElF-free gallons, also write this amount on Forms RMFT-5, Line Sa, Column 1 and RMFT-5-US, Line 8, Column 1. Ifyou are filing more than one Schedule 0, see instructions. RMFT-32 front (R-Q2/00) 

### 9 Invoiced gallons

## General Instructions This schedule is used for reporting the following taxes: Motor Fuel Tax (MFT) Underground StorageTank Tax (UST) 

### Environmental Impact Fee (EIF) 

## Which gasoline products must be reported on this shedule? The gasoline productsthat must be reported on this schedule are all products commonly or 

### commercially known orsold as gasoline (including casing-head and absorption or natural gasoline), gasohol, motor benzol, or motorbenzene, regardless oftheir classification or use. 

## When do I file this schedule? You must file Schedule D with Form RMFT-5 

### ifyou are reporiing MFT-free gallons only or both MFT

### and UST-/EIF-free gallons. 

### You mustfile Schedule D with Form RMFT-5-US 

### if you are reporting only UST-/EIF-free gallons. 

## What records must I keep? You are required by lawto keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What if I need additional assistance? Ifyou have questions about this schedule, write to us at Motor FuelTax, Illinois DepartmentofRevenue, P.O. Box 19477, Springfield, Illinois 62794-9477, or call ourSpringfield officeweekdays between 8 a.m. and 4:30 p.m. at217 782-2291. 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period forwhich you are reporting. Check the box next to the tax/fee type you are listing on this page. Report onetax/fee type only per page. 

## Step 2: Report your tax- and fee-free sales Lines 1through 10- Column 

### 1- Write the month, day, and year ofthe invoice. 

### Column 2 - Write the invoice number. 

### Column 3 - Write the carrier's complete business name. 

### Column 4 -Write the bill of lading or manifest number. 

### Column 

### 5

- Write the purchaser's complete name. 

### Column 6 - 

### Write the nameofthe Illinois city from which the gasoline product originated. 

### Column 

### 7

- Write the name ofthe Illinois city to which the gasoline product was delivered. 

### Column 8 - Writethe purchaser's IIJinois license number. 

### Column 9 - Write the numberof invoiced gallons. 

### Line 11 - Add the invoiced gallons reported in Column 9, Lines 1through 

# rn. Line 

### 12

- Ifyou arefiling morethan one Schedule 0, group togetherall Schedules D that report MFT-free gallons only. Add Lines 11 from this group, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5, Line Sa, Column 1. UST- and EIF-free gallons only. Add Lines 11 from this group, and write the total on Line 12 of the last page. Also write this amount on Form RMFT-S·US, Line 8, Column 1. both MFT- and UST-/EIF-free gallons. Add Lines 

### 11 from this group, and write the Iola! on Line 12 ofthe last page. Also write this amount on Form RMFT-5, Line Sa, Column 

### 1 and Form RMFT-5-US, Line 8, Column 1.

RMFT-32 back (R-02/00)**~** Thes form ,s authonzed tls ou~1ned by tl1o Motor Fuol Tax Law and !ho Environmenlal ltl!pacl Fee L«w. D,sciosure orti,,s onlormal1on is REQUIRED Fa,lurn lo ~tD'11de lnfurrnalmr, could result ,n a penulty.Th,s form has been npproV<!d by1110 Forms Mar,agemenl C€nlet. IL·4B2·1r,38

## ~~**~** 

# n ll .>is Department of Revenue 

# \J

# ::~o~~1~}o~oc:MFT-5-US Page
__of
__ 

# MFT, UST, and EIF Tax- and Fee-Paid Purchases Step 1: Completethe following information
Comp,my n~me Check the tax/fee type you are listing on this page. 

## D MFT-paid only Check the product type you are listing on this page. 

## [ l Gasoline products Your license n\1mb8i-" 

## LJ UST-IEIF-paid only 

## I I Combustible gases Reporting period

_ _ I _
__ _ 

## LJ Both MFT- and UST-/EIF-paid 

### [J Alcohol Montl1 Year 

## Step2: Reportyourtax- and fee-paid purchases 1 2 3 4 5 6 

### 7 8 Nameof Oripin Destinalion Seller's Invoice date (month, Uay. year) Invoice number carrier Bill oflading or manifestnumber Name ofseller (Illinois cilies only) , (Illinois cilies only) , license number 

### 1
__I _
_

### I

__ __ f--------+--- 

### -+------,----- -- -- ---- -- 

## 2
__ / __}__ -----1-------1---- -+--- 3
__ /
__,____ 

# ----+---- 

# -+- -- -----I

### 4
__ /
__ /
____ f----- 

### 5
__ !
__!____ 

### j

### 6
__ I
. I
___ 

### f------+------ 7 _ I I
____ f--------+----- 

### 8 --'--'---- f--------+------ 

### 9 __}
__ /
____ 1------·· 1-------j--- 

## c 10
__ /
__ /____ ---·-- 11 Add the invoiced gallons in Column 9, Lines 1 through 10, and write the total here. 12 See instructions.

Tl113 Fm,n ,s a,E!•1or1,:o,J ~s oullrn<l by lh>l Mntm Fuel Ta, Ulwaml Iha Env,rorimP'11al lrnpact fr" L<1·.v. D,sdOSLJW ofth1•, 1nf,,rma\1rn1 •s l<fOUIHEO Failllm lD f)fO\'lffo rnforrM!mn co,il<J m,ult 111 " per1ally Tills r,i:rn hd'J IJeeu dpp1•1w,d by 11,~ F,mns M"''·"Jemelll c,,r,t~, IL-~q:,.ooa1 RMFT·10front (g-3/01) 

### 11 

### 12 9 lnvoice<J gallons

## General Instructions This schedule is used for reporting the following taxes: Motor Fuel Tax (MFT) 

### • Underground StorageTank Tax (UST) • Environmental Impact Fee {Elf) 

## Which gasoline products must be reported on this schedule? The gasoline products that must be reported on this schedule are all products commonly or commercially known or sold as gasoline (including casing·head and absorption or natural gasoline), gasohol, motor benzol, or motor benzene. regardless oftheir classification or use. 

## When do Ifile this schedule? You must file Schedule E with Form RMFT-5 

### ifyou are reporting MFT-paid gallons only or MFT-, and UST-/EIF-paid gallons. You mustfile this schedule with Form RMFT-5-US 

### ifyou are reporting only UST-/EIF-paid gallons. 

## What records must I keep? You are required by law to l(eep books and records for at leastthree and one-halfyears showing all purchases, receipts, losses througl1 any cause. sales, distributions, and use offuels. You must keep the original invoice for each tax~ and fee-paid purchase identified on Schedule E. The invoice should be receipted "paid" and initialed by your supplier.You are not required to attach invoices to this schedule unless we request you to sendthem in. Ifwe do request your invoices to verify purchases, we will accept legible copies; however, we may require you send us the originals.

RMFT· TO back'

-- lt) 

## What

## if I need additional assistance? Ifyou have questions aboutthis schedule. write to us 

### al Motor Fuel Tax, Illinois Department of Revenue, 

### P.O. Box 19477. Springfield. Illinois 62794-9477, or call our Springfield officeweekdays between 

### 8 a.m. and 4:30 p.m. at 217 782-2291. 

## Step-by-Step Instructions Step 1: 

## Complete the following 

## information Write your company name, your license number, and tile period forwllich you are reporting. Check the box next to the tax/fee type and the product type you 

### are listing on this page. Report one 

### lax/ fee type and one product type per page. 

## Step 2: Report yourtax- and fee-paid purchases Lines 

### 1 through 

### 10- Column 

### 1**~**

### Write the rnonth, day, and year ofthe invoice. Column 

### 2 - Write the invoice number. Column 

### 3 -Writethe caiTier's complete business name. Column 4**~**

### Write the bill of lading or manifest number. Column 5 -Write the seller's complete name. Column 6 - Write the name ofthe ltlinois cityfrom which the gasoline product originated. Column 7 - Write the name ofthe Illinois city lo which the gasoline productwas delivered. Column 8 - Writethe seller's Illinois license number. Column 9 -Write the numberof invoiced gallons. Line 11 - Add the invoiced gallons reported in Column 9, Lines 1 through 10.**~** 

### Line 12 - !fyou are filing only one Schedule E, write the amountfrom line 

### 11 on Line 12. Ifyou are reporting • gasoline products and MFT-paid on!y, also write this amount on Form RMFT-5, lines 2b and 17, Column 

### 1. UST-/EIF-paid only, also write this amount on Form RMFT-5-US, Lines 2band 

### 12, Column 

### 1. both MFT- and UST-fEIF-paid, also write this amount on Form RMFT-5, Lines 2b and 17, and Form RMFT-5-US, Lines 2b and 

### 12, Column 

### 1. combustible gases, alcohol, and

.. MFT-paid only, alsowritethis amount on

Form RMFT-5, Line 17, Column 

### 1. UST-fEIF-paid only, also write !his amount on Form RMFT-5-US, Line 

### 12, Column 

### 1 both MFl:. and US-/E!F-paid, also write this amount on Form RMFT-5, Line 

### i7, Column 

### ·1, and Form RMFT-5-US. Line 12. Column 1. Ifyou are filing more than one Schedule E, group together all Schedules E that report gasoline products and MFT-paid 

### only. Cc1II this group "A." gasoline products and UST-/EIF-paid only. Call this group 

### "B." gasoline products and both MFT- and UST-/E!F-paid. Call this group "C." • combustible gases, alcohol, and MFT-paid only. Call this group "D." • combustible gases, alcohol, and UST-/EIFpaid only. Call this group "E." combustible gases, alcohol, and both MFT- and UST-/ElF-paid. Call this group "F." Add Lines 11 from each group, and write the total amounton Line 12ofthe !asl page of each group. Then add Line 12 from

groupsA and C, and write this amount on Form RMFT-5, Lines 2b and 17, Column 1. groups B and C, and write this amount on Form RMFT-5-US, Lines 2b and 12, Column 1. groups D and F, and write t11is amount on Form RMFT-5, line 17, Column 1. groups E and F, and write this amount on Form RMFT-5-US, line 12, Columr--t 

# tl

# - {) 1: ois Department of Revenue 

# MFT, uST, and EIF Page
__of
__ 

# Schedule DA Dyed Diesel Fuel Produced, Attach 

### to Focm RMFT-5 oc Focm RMFT-5-US 

# Acquired, Received, orTransported into Illinois Step 1: Complete the following information
Company name Check the tax/fee type you are listing on this page. 

## O MFT-free only Check the receipt lype you are listing on this page. 

## O Dyed diesel fuel received in lllinois Your license number 

## O UST-/E!F-free only Reporting period
__ /
___ _ 

## O Both MFT- and UST-/EIF-free Month Year 

# Step 2: Reportyourtax- and fee-free purchases 1 Invoice date (month, day, year) 

### 1 

# __

# , __ /

### ____ 2 __ /
__ !
____ 

### 3 

### __)

# __ / 

### ____ 4 __ !
__

### !
____ 

### 5 __!
__!
____ 

### 6 __ !
__ {
____ 

### 7 

### __ / 

### __ / 

### ____ 8 

# --'--'---- 9 __ !
__ {
____ 

### 10 __ ,__ !
____ 

### 2 Invoice number 

### 3 Name of carrier 

### 4 Bill oflading or manifest number 

### 5 Name ofseller 

### 6 Origin (cily and slate) 

## D Dyed diesel fuel imported into Illinois 

## O Dyed diesel fuel produced in Illinois



### 7 Destination (Illinois cities only) 

### 8 Seller's license number



### 11 Add the invoiced gallons in Column 9, Lines 1through 10, and write the total here. 11 9 Invoiced gallons



### 12 Ifyou are filing only one Schedule DA, write the amount from Line 11 here. 12
______ _ !fyou are reporting MFT-free gallons only, also write this amount on Form RMFT-5, Line 2a, Column 3. • UST-/EIF-free gallons only, also write this amount on Form RMFT-5-US, Line 2a, Column 1. • both MFT- and UST-/EIF-free gallons. also write this amount on Form RMFT-5, Line 2a, Column 3, and Form RMFT-5-US, Line 2a, Column 1. Ifyou are filing more than one Schedule DA, see instructions. 

### "',>,".,C,,","m"os",",,",,,","1,eo=.=,,c,,c,,,c'"c'c•c''_"_M_M_m_,c,c•'_'"_"_'_m,-,-,-,-,,-,-,,-,-.,-,-m-.,-,,-,-,m-,-ao-,-~-.-,-,w~O-,sc-,,-,-,,-,-,,-,-,,,-m-,,-,-m-a0-,-,

# -.,-,-rn-,-,-ae-,-, RMFT-6-DFfronl (N-1WJ9) Failure 10 pmv1Je tt1fomrnl,on cm1IO rosult in a penalty This form husbeenapprovedby lhe Forms M~nay~menl Cer,ter IL-492-3960

## General Instructions Schedule DA is usedfor reporting the following taxes: Motor Fuel Tax {MFT) Underground StorageTank Tax (UST) Environmental Impact Fee (EIF) 

## What is dyed diesel fuel? Dyed diesel fuel is any special fuel that has been dyed per Section 4d ofthe Motor Fuel Tax Law. 

## When do I file this schedule? You mustfile Schedule DAwith Form RMFT-5, Motor Fuel Distributor/SupplierTax Return, 

### ifyou are reporting MFT-free gallons only or both MFTand UST-/EIF-free gallons. Ifyou are a distributor orsupplier, you must report all dyed diesel fuel transactions as MFT-free. You mustfile Schedule DAwith Form RMFT-5-US, Underground StorageTank Tax and Environmental Impact Fee ReceiverTax Return, ifyou are reporting only UST-/EIF-free gallons. 

## What must I attach to this schedule? You mustattach the credlt invoices issued bythe sellerto Schedule DA.We will return your credit invoices to you upon request. 

## What records must I keep? You are required by lawto keep books and records showing all purchases, receipts, losses through anycause, sales, distributions, and use of fuels.

RMFT·6·DFt,mc'-.12/99) 

## What if I need additional assistance? lfyou have questions about this schedule, write to us al Motor FuelTax, Illinois Department ofRevenue, P.O. Box 19477, Springfield, lllinols 62794-9477, or call our Springfield office weekdays between 8 a.m. and 4:30 p.m. at 2"17 782-2291. 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period for which you are reporting. Check the boxes nextto the tax/fee type and the receipt type you are listing on this page. Report one tax/fee type and one receipt type only per page. 

## Step2: Reportyourtax- and fee-free purchases Lines 

### 1 through 

### 10- Column 1 - Writethe month, day, and year ofthe invoice. Column 2 - Write the invoice number. Column 3 - Write the carrier's complete business name. Column4 - Write the bill of lading or manifest number. Column 5 - Writethe seller's complete name. Column 6 - Write the city and the state (using the two-character U.S. Post Office abbreviation) from which the dyed diesel fuel product originated.**~** 

### Column 7 -Write the name ofthe Hlinois city to which the dyed diesel fuel product was delivered. Column 8 - Write the seller's Illinois license number. Column 9 - Writethe number of invoiced gallons. Line 11 -Add the invoiced gallons reported in Column 9, Lines 1through 10. Line 12- Ifyou are filing more than one Schedule DA, group together all Schedules DA that report MFT-free only gallons. Add Lines 11 from this group, and write the total on Line 12 ofthe last page. UST-IEIF-free only gallons. Add Lines 11 from this group, andwrite the total on Line 12 ofthe last page. both MFT- and UST-/EIF-free gallons. Add Lines 11 from this group, and write the total on Line 12 ofthe last page. Then, addthe totals from Lines 12 ofthe Schedules DAthat report MFT-free gallons only group and the both MFT- and UST-/EIF-free gallons group and write this amount on Form RMFT-5, Line 2a, Column 3. UST-/EIF-free gallons only group and the both MFT- and UST-/EJF-free gallons group and write this amount on Form RMFT-5-US, Line 2a, Column 1.



# - t1**~** 

# \] l1i,.1ois Department of Revenue 

# Schedule DD MFT, UST, and EIF Dyed Diesel Fuel Sold and Distributed Tax- and Fee-Free in Illinois to Licensed Distributors or Suppliers Attach to Form RMFT-5 or Form RMFF-5-US 

### Page
__of
__ 

## Step 1: Complete the following information
Company name Check the taxffee type you are listing on this page. 

## O MFT-free only Your license nuinber Reporting period

_ _ 

### f

_ __ _ Month Year 

## Step2: Reportyourtax- andfee-free sales and distributions 1 Invoice date (month, day, year) 

### 1 

# __ / 

# __ / 

# ____ 2 

# __ / 

# __

# , ____ 3 __ /
__!
____ 4 

# _ _/



# __

# , ____ 5 

# __ /

# __ /

# ____ 6
_ _;__ !
____ 

### 7 

# __

# , __ /


### ____ 

### 8 __ !
__ !
____ 

### 9 __ ,__ !
____ 

### 10
__ /
__ !
____ 

### 2 Invoice number 

### 3 Nameof carrier 

### 4 Bill oflading or manifestnumber 

### 5 Name ofpurchaser 

### 6 Origin (Illinois cities only) 

## O UST-/EIF-free only 

## O Both MFT- and UST-/EIF-free



### 7 Destination (Illinois cities only) 

### 8 Purchaser's license number



### 11 Add the invoiced gallons in Column 9, Lines 1through 10, and write the total here. 11 

### 9 Invoiced gallons



### 12 Ifyou are filing only one Schedule 00, write the amount from Line 11 here. 12
______ _ lfyou are reporting MFT-free gallons only, also write this amount on Form RMFT-5, Line 8a, Column 3.

, UST-/EIF-free gallons only, also write this amount on Form RMFT-5-US, Line 8, Column 1. • both MFT- and UST-/ElF-free gallons, also write this amount on Forms RMFT-5, Line Sa, Column 3, and RMFT-5-US, Line 8, Column 1. Ifyou are filing more

### than one Schedule DD, see instructions. 

### ''=,a-os=,e-,-m=,,-,-,,>,,-,0 ;..,.~d,-,-,,-,,c,,·.,c,-,=,,,-,cMcMcmc,c,c,,c,.-,c,-,w-,-,c,c,,,-,c,m-,m-,---,-,,c,c,m-,-ac","e,-, 0 ,-,w-.=,-,mcfo-,-,,-,cMc"-'"-'"c"-'"-'c"-'°'-"-,","rn"c","ss"c"."' Failure lo provide 1nforma!,on could result •n apenally. Tl11s fom1 has been appmve<J by tl1e F<,,n,s Mar,agemeotlCenler IL-4U2.:1983 RMFT-32-0Ffront (N-12/99)

## General Instructions Schedule DD is usedfor reporting the following taxes: Motor FuelTax (MFT) Underground StorageTankTax (UST) Environmental Impact Fee (EIF) 

## What is dyed diesel fuel? Dyed diesel fuel is any special fuel that has been dyed per Section 4d ofthe Motor Fuel Tax Law. 

## When do I file this schedule? You mustfile Schedule DD with Form RMFT-5, Motor Fuel Distributor/SuppllerTax Return, 

### ifyou are reporting MFHree gallons only or both MFTand UST-/EIF-free gallons. You mustfile Schedule DD with Form RMFT-5-US, Underground StorageTank Tax and Environmental Impact Fee ReceiverTax Return, 

### ifyou are 

### reporting UST-/ElF-free gallons only. 

## What records must I keep? You are required by lawto keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What 

## if I need additional assistance? Ifyou have questions aboutthis schedule, write to us at Motor FuelTax, !llinois Departmentof Revenue, 

### P.O. Box 19477, Springfield, Illinois 

### 62794-9477, or call ourSpringfield office weekdays between 

### 8 a.m. and 4:30 p.m. at 

### 217 782-2291.

RMFT·32·DF b~~N-12/99) 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period forwhich you are reporting. Check the boxes nexttothe tax/fee type you are listing on this page. Report one tax/fee type per page. 

## Step 2: Report yourtax- and fee-free sales Lines 

### 1through 

### 10

- Column 

### 1 - Write the month, day, and year ofthe invoice. Column 

### 2 - Write the invoice number. Column 

### 3 -Write the carrier's complete business name. Column 4 -Write the bill of lading or manifest number. Column 

### S •Write the purchaser's complete name. Column 

### 6 -Writethe nameofthe Illinois city from which the dyed diesel fuel product originated. Column 

### 7 •Write the name of!he Illinois city to which the dyed diesel fuel productwas delivered. Column 

### 8 - Write the purchaser's Illinois license number. Column 

### 9 - Write the numberoflnvoiced gallons. Line 

### 11 · Add the invoiced gallons reported in Column 9, Lines 1 through 10.**~** 

### Line 12 - Ifyou are filing more than one Schedule 

### DD: First, grouptogether all Schedules 

### DD that report UST-/EIF-free only gallons.Add Lines 

### 11 from this group, and writethe total on Line 

### 12 ofthe last page. MFT-free only gallons.Add Lines 

### 11 from this group, and write the total on Line 

### 12 ofthe last page. both MFT~ and UST-fEIF-free gallons. Add Lines 

### 11 from this group, and write thetotal on Line 

### 12 ofthe last page. Then, add thetotalsfrom Lines 

### 12 ofthe Schedules 

### DD that report UST-fEIF-free only gallons and both MFT~ and UST-/EIF-free gallons and write this amount on Form RMFT-5-US, Line 8, Column 

### 1. MFT-free only gallons and both MFT- and UST-/ EIF-free gallons andwritethis amount on Form RMFT-5, Line 8a, Column 

### 3.



### t~

# - 

# {) 111..,ois Department of Revenue 

# Schedule LA UST and EIF Page
__of
__
Attach to Form RMFT-5-US 

# Fuels OtherThan Gasoline Products and Special Fuels Produced,Acquired, Received, orTransported into Illinois Step 1: Completethefollowing information
Company name Check the receipt type you are listing on this page. 

## O Otherfuel products received in Illinois Your license number 

## D otherfuel products imported into Illinois Reporting period

_ _ !

_ __ _ 

## D Other fuel products produced in your Illinois refinery Month Year 

# Step 2: Reportyourtax- andfee-free purchases 1 2 3 

### 4 5 6 

### 7 B Invoice date Invoice Name of Bill oflading or Product Origin Destination (month, day, year) number carrier manifest number code Name ofseller (city and slate} (lllinois cities only) (see instr.) 

### 1 

# __{ 

# __{ 

### ____ 2 

### __ { 

### __ { 

# ____ 3 

# __{ 

# __ / 

# ____ 4 

### __ / 

### __)

### ____ 5 _ _/
__ !
____ 

### 6 

# __ / 

### __) 

# ____ 7 

# --'--'---- B 

# _ _)

# __ / 

# ____ 9 _ _!
_ _)
____ 

### 10 

## __L_I
____ 11 Add the invoiced gallons in Column 10, Lines 1through 10.Write the total amount here. 12 lfyou arefiling only one Schedule LA, write the amount from Line 11 here and on Form RMFT-5-US, Line 2a, Column 2. Ifyou arefiling morethan one Schedule LA, add Line 11 from each schedule, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5-US, Line 2a, Column 2.

RMFT-16 front (R·02/00) This form ,s aulhor,wd asoutlined by the Motor FuelTa< law andIha Env,ronmantal Impact Fee Law. D,sdosureufthis lnformaiur1 is fl.EQUIFlED Failure lo provtde 1nformal1on could rcsull 1n a penally Th,s form hasbeenapproved by ll,e Forms Managernant Center IL·492-2311 

### 9 

### 10 Seller's Invoiced license number gallons



### 11 

## 12

## General Instructions This schedule is usedfor reporting the following taxes: Underground StorageTank Tax (UST) • Environmental Impact Fee (EIF) 

## Which fuels must be reported on this schedule? Thefuels that must be reported on this schedule include aviation fuel and 1-k kerosene. Do not report any type of kerosene otherthan 1-k kerosene on this schedule. 

## When do Ifile this schedule? You mustfile Schedule LA with Form RMFT-5-US. 

## What must I attach to this schedule? You must attach the credit invoices issued bythe sellerto Schedule LA.We 

### will return your credit invoices to you upon request. 

## What records must I keep? You are required 

### by lawto keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What 

## if I need additional assistance? Ifyou have quesllons about this schedule, write to us at Motor Fuel Tax, Illinois Department of Revenue, P.O. Box 19477, Springfield, Illinois 62794-9477, or call ourSpringfield officeweekdays between 8a.m. and 4:30 p.m. at217 782-2291.

RMFT-16 back (R-02100) 

## Step-by-Step Instructions Step 1: Complete the following information Write yourcompany name, your license number, and the period for which you are reporting. Check the box nextto the receipttypeyou are listing on this page. Report one receipt type only per page. 

## Step 2: Reportyourtax- and fee-free purchases Lines 1through 

### 10- Column 1 - Write the month, day, and year ofthe invoice. Column 2 - Write the invoice number. Column 3 - Write the carrier's complete business name. Column 4 - Write the bill oflading or manifest number. Column 5 - Write the product code. AVI - aviation fuel 1 K - 1-k kerosene OTH - other Column 6 - Write the seller's complete name. Column 7 - Write the city and state (using the two-character U.S. Post Office abbreviation) from which the fuel product originated. Column 8 -Writethe name ofthe Illinois city to which the fuel product was delivered. Column9 - Write the seller's Illinois license number. Column 10 - Write the numberofinvoiced gallons.



# - Line 

### 11 -Add the invoiced gallons reported in Column 10, Lines 1through 10. Line 12 - If you are filing only one Schedule LA, write the amount from Line 11 on Line 12 and on Form RMFT-5-US, Line 2a, Column 2. Ifyou are filing more than one Schedule LA, add Line 11 from each schedule, and write the total on Line 12 ofthe last page. Also writethis amount on Form RMFT-5-US, Line 2a, Column 2.



# ,')

# - Page
__ of
__ 

# n s~ih;d~i;trevenue

\J Attach to Form RMFT-5-US 

# UST/EIF Exemption for Sales of Aviation Fuels, Kerosene, and Diesel Fuel Step 1: Completethe following information
Company name Your licensenumber Reporting period
__ /_
_ Month Year 

# Step 2: Report your exempt sales 1 lrwoice date (month, day, year) 

### 1 __J
_ _J_ - - - 

### 2

__ I
__I 

### 3
__!
__!
____ 

### 4 __!
__!
____ 

## 5
__ /
__ /
____ 6 __ , __!
____ 

### 7 __ !
__ !
____ 

### 8 _.)_.)
____ 9 __/
__ ,____ 10 _.)_.) 

# ____ 2 Invoice number 

### 3 Nameof carrier 

### 4 Bill of lading or manilost numbor 

### 5 Name of purchaser



### 11 Add the invoiced gallons in Column 8, Lines 1 through 10.Write the total amount here. 12 Ifyou are tiling only one Schedule LB, write the amountfrom Line 11 here. Ifyou are reporting • diesel fuel sold to railroads, alsowrite this amount on Form RMFT-5-US, Line 6a, Column 

### i. Check the product type you are listing on this page. 

## D Diesel fuel sold to railroads 

## O Diesel fuel sold to qualified ships, barges, and vessels 

## D Kerosene sold to qualified aircarriers 

## O Aviation fuel sold to qualified air carriers 

## 0 1-k kerosene sold to qualified aircarriers



### 6 7 Airport name Dastination (sales lo air carriers only), (lllinois citios only) 

### 8 Invoiced gallons



### 11
_____ _

• diesel fuel sold to ships, barges and vessels, also write this amounton Form RMFT-5-US, Line Be, Column 1. • kerosene sold to air carriers, also write this amounton Form RMFT-5-US, Line 6b, Column 1. • aviation fuel or 1-k kerosene sold to air carriers, also write this amounton Form RMFT-5-US, Line 6b, Column 2. Ifyou arefiling more than one Schedule LB, see instructions.
RMFT-17 front (R·09/01) 

### 12
______ _

## General Instructions This schedule is usedfor reporting the following taxes: • Underground StorageTankTax (UST) • Environmental Impact Fee (EJF) 

## Which fuels must be reported on this 

## schedule? The fuels that must be reported on this schedule include aviation fuel, kerosene, and diesel fuel 

### when the following conditions are met: 

### Aviation fuel and kerosene are exempt if

### these products are for sale or use at airports with more 

### than 170,000 operations peryear, located in cities of morethan 1 million inhabitants, and 

### • soldto or used by 

### holders of certificates of public convenience and necesssity orforeign air carrier permits, issued by the U.S. Department ofTransportation, and their alr carrier affiliates, 

## o, • received atfacilities owned or leased by the certificate or permit holders and used in their activities atthese airports. Diesel fuel is exempt if it is: • sold to a rail carrier registered underthe Illinois Vehicle Code, Section 1Bc-7201, or recognized by the Illinois Commerce Commission as a rail carrier, and used directly in railroad operations. • consumed or used in the operation ofships, barges, orvessels, all ofwhich are used primarily in orforthe transportation of property in interstate commerce for hire on rivers bordering l!inois, if the diesel fuel is delivered by a licensed receiver to the purchaser's barge, ship, orvessel while it is afloat upon a bordering river. 

## When do I file this schedule? You must file this schedule with your Form RMFT-5-US. 

## What records must I keep? You are required by law to keep books and records showing all purchases, receipts, tosses through any cause, sales, distributions, and use offuels. 

## What 

## if I need additional assistance? Ifyou have questions about this schedule, write to us at Motor FuelTax, Illinois Department of Revenue, P.O. Box 19477, Springfield, lllinois 62794-9477, or call ourSpringfield office weekdays between 8 a.m. and 4:30 p.m. at217 782-2291. 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period for which you are reporting. Check the box next to the producttypeyou are listing on this page. Report one producttype only per page. 

## Step 2: Reportyourexempt sales Lines 1 through 1O - 

### Column 1 - Writethe month, day, and year ofthe invoice. Column 2 - Write the invoice number. Column 3 - Writethe carrier's complete business name. Column 4 - Writethe blll of lading or manifest number. Column 5 - Write the purchaser's complete name. Column 6 - lfthe sate was madeto a qualified air carrier, write the name ofthe airportto which the productwas delivered. Do notwrite anything in this column ifthe sale was made to a qualified rail carrier, ship, barge, or vessel. Column 7 - Writethe name ofthe Illinois city to which the productwas delivered. Column 8 - Writethe amountof invoiced gallons. Line 11 - Add the invoiced gallons reported in Column 8, Lines 1through 10. Line 12- Ifyou arefiling morethan one Schedule LB, group together all Schedules LB that report • diesel fuel sold to railroads. Add Lines 11 from this group, andwrite the total on Line 12 of the last page. Also write this amount on Form RMFT-5-US, Line 6a, Column 1. • diesel fuel sold to qualified ships, barges, and vessels. Add Lines 11 from this group, and write the result on Line 12 ofthe last page. Also write this amount on Form RMFT-5-US, Line 6c, Column 1. • kerosene sold to qualified air carriers. Add lines 11 from this group, and write the total on Line 12 of the last page. Also write this amount on Form RMFT-5-US, Line 6b, Column 1. • aviation fuel and 1-kerosene sold to qualified air carrlers. Add Lines 11 from this group, and write the total on Line 12 ofthe last page. Also write this amounton Form RMFT-5-US, Line 6b, Column 2.

RMFT-17 back (.l,U)/01) This forrn ,s aulhodzed as outl:r,ed by IM Molo, FuelTax law and Iha E:nv,ronmon!al Impact fee Low. o,sc!osure of tills 1nforrna11on 10 REQUIRED Failure lO provide mlormal,on could resull m o penalty.Thts form Ms bec........,prov~d hy lho Forms Man~gemerll Ge<\ter ll-492-2312 

# - t)

# {) 1; Jis 

### Department of Revenue 

# u..,r and EIF 

# Schedule LC Attach to Form RMFT-5-US 

# Sales andTransfers of Fuels OtherThan Gasoline Products and Special Fuels Delivered to Points Outside of Illinois Step 1: Completethe following information Page
__of
__

Company name Check the producttype you are listing on this page. 

## D Aviation fuel Your license number 

## 0 1-k kerosene Nameo[slatO tiitowhich shipmentswere made Reporting period
__ /
___ _ 

## O Other (specify:------------ Month Year 

## Step 2: Reportyour exported gallons 1 

### 2 3 Invoice dale Invoice Name of (month, day, year) number carrier 

### 1 

### __ / 

# __

# , ____ 2 _ _)
__ !
____ 

### 3 __ ,__ !
____ 

### 4 __ ,__ !
____ 

### 5 __ {
__!
____ 

### 6 __ !
__ /
____ 

### 7 

# __{ 

### __ / 

### ____ 8 __ !
__ {
____ 

### 9 

### __ { 

# __

# , ____ 10

# __{ 

# _

_}



### ____ 4 Bill oflading or manifestnumber 

### 5 Nameof purchaser



### 11 Add the invoiced gallons in Column 8, Lines 1through 10.Write the total amount here. 

### 6 Origin (Illinois cities only)



### 12 lf

### you are filing only one Schedule LC, write the amountfrom Line 11 here and on Form RMFT-5-US, Line 7, Column 2. Ifyou are filing more than one Schedule LC, add Line 11 from each schedule, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5-US, Line 7, Column 2.

RMFT-13front (R-02/00) This lorn, is aulhonzod as ouu,ned bylhc Mole>r Fuel faK Law aml the En"'romnenlal Impact Fee Law. Disclosure of l!\is rnfomial1on 1s REQUIRED. Failure to pruvade 111formaltot1 could result 1n a pe11alty.This form llas lleen approved lly U,e fotrns Man,iyernenl Center. ll-4S2-2:J14 

### 7 Destination (city and state) 

### 8 Invoiced gallons



### --~ 

## -,-

11
_____ _ 

### 12
_____ _

# General Instructions This schedule is used for reporting the following taxes: Underground StorageTankTax (UST) • Environmental Impact Fee (EIF) 

## Which fuels must be reported on this schedule? The fuels that must be reported on this schedule include aviation fuel and 1-k kerosene. Do not report anytype ofkerosene otherthan 1-k kerosene on this schedule. 

## When do I filethis schedule? You mustfile Schedule LC in duplicatewith 

## Form RMFT-5-US. 

## What records must I keep? You are required by lawto keep books and 

### records showing all purchases, receipts, losses through any cause, sa!es, distributions, and use of fuels. 

## What 

## ifI need additional assistance? !fyou have questions aboutthis schedule, write to us 

### at MotorFuelTax, Illinois Department of Revenue, P.O. Box 19477, Springfield, lllinois 62794-9477, or call our Springfield office weekdays between 8 a.m. and 4:30 p.m. at 217 782-2291.

RMFT-13 backp=•··fl2/00) 

# Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, the period forwhich you are reporting, and the state into which you madefuel sales ortransfers. Check the box nextto the producttype you are llsting on this page. Report one state and one producttype only per page. 

## Step 2: Reportyourexported gallons Lines 1through 1

### D - Column 1 - Write the month, day, and year ofthe invoice. Column 2 - Write the invoice number. Column 3 - Write the carrier's complete business name. Column 4 -Write the bill oflading or manifest number. Column 5 - Write the purchaser's complete name. Column 6 -Write the name ofthe Illinois city from which the fuel product originated. Column7 - Write the city and state {using the two-character U.S. Post Office abbreviation) to which the fuel product was delivered. Column 8 -Writethe numberof invoiced gallons.



# - Line 11 - Add the invoiced gallons reported in Column 

### 8, Lines 

### 1through 

### 10. Line 

### 12- lfyou are filing only one Schedule LC, write the amountfrom Line 

### 11 on Line 

### 12 and on Form RMFT-5-US, Line 7, Column 2. lfyou are filing more than one Schedule LC, add Line 

### 11 from each schedule, and write the total on Line 

### 12 ofthe last page. Also write this amount on Form RMFT-5-US, Line 

### 7, Column 

### 2.



# "' 

# ,



# ..

# {) lh
..1ois 

## Department of Revenue 

# UST and EIF 

# Schedule LD Attach to Form RMFT-5-US 

# Fuels OtherThan Gasoline Products and Special Fuels SoldTax- and Fee-Freeto Other Licensed Receivers in Illinois Step 1: Complete the following information Page
__of
__

Company name Check the product type you are listing on this page. 

## D Aviation fuel Your license number 

## 0 1-k kerosene Reporting period

_ _ 

### t _ __ _ 

## D other (specify:
__________ _ Month Year 

# Step 2: Reportyourtax- and fee-free sales 1 

### 2 Invoice date Invoice (month, day, year) number 

### 1 

# --'--'---- 2 __ / 

# __ / 

# ____ 3 _ __)
__ !
____ 

### 4 __!
__ !
____ 

### 5 __ ,__ !
____ 

### 6 __!
__!
____ 

### 7 

### __)

### __ / 

### ____ 8
_ _)
_ _!
____ 

### 9 

### __ / 

# __

# , ____ 10 

### __ / 

### __ / 

# ____ 3 Name of carrier 

### 4 Bill

### oflading or manifest number 

### 5 Name of purchaser 

### 6 Origin {Illinois cities only) 

### 7 Destination (Illinois cities only}



### 11 Add the invoiced gallons in Column 9, Lines 1through 10.Write the total amount here. 12 

### !fyou are filing only one Schedule LO, write the amount from Line 11 here and on Form RMFT-5-US, Line 8, Column 2. lfyou are filing more than one Schedule LO, add Line 11 from each schedule, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5-US, Line 8, Column 2.

RMFT-15 front (R-02/00) This form Is HUthonze<i as ouU1ned l>y tile Molor Fual T.1x Law and \ho Environmental lmract Feo Law. D,sclosum of lhis mfor!mll1on is REQUIRED Failure to provide information coul<i resu:! ,n a pen~lty Th,s form has been aporoved by lhe Forms Management Center. IL-492·2~15 

### 8 Purchaser's license number 

### 9 Invoiced gallons



### 11
_____ _ 

### 12
_____ _

## General Instructions This schedule is used for reporting the following taxes: Underground StorageTankTax (UST) • Environmental Impact Fee (E!F) 

## Which fuels must be reported on this schedule? Thefuels that must be reported onthis schedule include aviation fuel and 1-k kerosene. Do not report anytype of kerosene otherthan 1-k kerosene on this schedule. 

## When do I filethis schedule? You mustfile Schedule LO with Form RMFT-5-US. 

## What records must I keep? You are required by law to keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What 

## if I need additional assistance? If

### you have questions aboutthis schedule, write to us at Motor FuelTax, Illinois DepartmentofRevenue, P.O. Box 19477, Springfield, Illinois 62794--9477, or cal! ourSpringfield office weekdays between 8 a.m. and 4:30 p.m. at217 782-2291.

RMFT-15 back (R-02/00) 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period for which you are reporting. Check the box nextto the producttype you are listing on this page. Report one producttype only perpage. 

## Step 2: Report yourtax- and fee-free sales Lines 1 through 10- Column 1 - Write the month, day, and year ofthe invoice. Column 2 - Write the invoice number. Column 3 - Write the carrier's complete business name. Column 4 - Write the bill of lading or manifest number. Column 5 - Write the purchaser's complete name. Column 6 -Writethe name ofthe Illinois city from which the fuel product originated. Column 7 -Writethe name ofthe Illinois city to which the fuel productwas delivered. Column 8 - Writethe purchaser's lllinois license number. Column 9 - Write the numberofinvoiced gallons.**~** 

### Line 11 -Add the invoiced gallons reported in Column 9, Lines 1through 10. Line 12 - Ifyou are filing only one Schedule LO, write the amountfrom Line 11 on Line 12 and write this amounton Form RMFT-5-US, Line 8, Column 2. Ifyou are filing more than one Schedule LO, add Line 11 from each schedule, and write the total on Line 12 ofthe last page.Alsowrite this amounton Form RMFT-5-US, Line 8, Column 2.



# -**~~**

# - 

# \] II Jis Department of Revenue 

# Schedule LE Attach lo Form RMFT-5-US 

# US. and EIF Tax- and Fee-Paid Purchases ofthe

FuelTypes SubjectOnlyto UST/EIF Step 1: Complete the following information 

# - Page
___ of
__

Company name Check the product type you are listing on this page. 

# r1 Aviation fuel



### --------------·······-- Your license number 

## L I 1-K kerosene 

# rJ Dyed diesel fuel Reporting period
__ /
__ _ 

## D Other {specify: Month Year 

## Step 2: Report your tax- and fee-paid purchases 1 

### 2 3 

### 4 5 6 7 8 Invoice date Invoice Name of Origin Deslinat1on Seller's (month, day, year) number carrier Bill oflading or manifestnumber Name of seller (Illinois cities only) (Illinois citie$ only) license number 

### 1 __! _ _/
____ 

### 2
__ /
__I
____\.---·---- 

### -1- 

### 3
__1
__1
____1

--


### --- ---·--1---- 

### 4
__/
__ / ----1-~-· --<----------- ----+---- 

### 5 

### ./ .J.
_____, __________,,,,1 

## ---1

------ 6
__ /
__ /
____

### C-------+-- 

## ---+--- 7
__ /
__ !_ 

### 8
__ /
__ /
____ 

### !------+--------+-----+-------- 9 / __/___ 

# 1-~-- 10
__ /
__ /
____~----~------~----~-------- -··- 11 Add the invoiced gallons in Column 9, Lines 1through 

### iO. Write the total amount here. 12 If you are filing only one Schedule LE, write the amountfrom Line 11 here and on Form RMFT-5-US, Lines 2b and 12; dyed diesel fuel, Column 1; otherfuels, Column 2. 

### !fyou are filing more than one Schedule LE, add Line i 1from each, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5-US, Lines 2b and 12; dyed diesel fuel, Co!unm 1; other fuels, Column 2. RMFT.18 front (R-3i01) ""'"'"" ,,, """"'""''" ,,_ 0011"1"" U'flhe li,11,,r fuel !ax L,w atld the Em1r,mm~,;i;;·l;;;1rnct f~o Law DisclosHn~ofthis

### ,t,f,,,,,;,,i,ni, isHFOUllllii] F,s,lu,e to l~l_•\f_e_LflfD•n1,,1,m, '·l''"d resull_"'-'' p~r1._,l(Y_!h1~ lurrn 11~, ~en_fl'~~v~_<I ily ltw forms M,>nug~•Mnl_CeFllF'L IL-192-2.11:1 

### 11 12 9 Invoiced gallons

---

## General Instructions Schedule LE is used for reporting the 

## following taxes: Underground StorageTank Tax (UST) Environmental lmpact Fee (EIF) 

## Which fuels must be reported on this schedule? The fuels that must be reported on !his schedule 

### include aviation fuel, dyed dieselfuel, and 1-K kerosene. Do not report any type of kerosene other than 1-K kerosene on this schedule. 

## What is dyed diesel fuel? Dyed diesel fuel is any special fuel that has been dyed per Section 4d ofthe Motor Fuel Tax Law. 

## When do Ifile this schedule? You mustfile Schedule LEwith Form RMFT-5-US. 

## What records must I keep? You are required by law to keep books and records 

### for at leastthree and one-halfyears showing all purchases, receipts, losses through any cause, sales, distributions, and use offuels. You must keep the original invoice for each laxand fee-paid purchase identified on Schedule 

### LE. The invoice should be receipted "paid" and inili81ed by your supplier.You are not required to attach invoices to this schedule unless we request you to send them in. lfwe do request your invoices toverify purchases, we will accept legible copies; however, we may require you send us the originals.

RMFT·18 back ( I) 

## What ifI need additional assistance? Ifyou have questions aboutthis schedule, write to 

### us 

### at Motor Fuel Tax, Illinois Department of Revenue, 

### P.O. Box 19477, Springfield, Illinois 62794-9477, or call our Springfield office weekdays between 

### 8 a.m. and 

### 4:30 p.m.

### at 217 782-2291. 

## Step-by-Step Instructions Step 1: Complete the following information Write your company nalile, your license number, and the period for which you are reporting. Check the box next to the product type you are listing on this page. Report one producttype only per page. 

## Step 

## 2: Report your

## tax- and fee-paid purchases Lines 

### ·1 through 

### 10

- Column 

### 1 · Write the month, day, and yearof the invoice. Column 

### 2 •Write the invoice number. Column 

### 3 · Write the carrier's complete business name. Column 

### 4 •Write the bill of lading or manifest number. Column 5 •Write the seller's complete name. Column 6 · Write the name ofthe Illinois city from which the fuel product originated.**~** Column 7 •Write the name ofthe Illinois city 

### to which the fuel productwas delivered. Column

### 8

- Write the seller's Illinois license number. Column 

### 9 •Write the numberof invoiced gallons. 

### Llne 11 •Add the invoiced gallons reported in Column 9, Lines 1 through 10. Line 

### 12 • !fyou are filing only one Schedule 

### LE, write the amountfrom Line 

### 11 on Line 

### 12 and on Form RMFT-5-US, Lines 2b and 

### 12: dyed diesel fuel. Colurnn 

### 1; other fuels, Column 

### 2. Ifyou are filing more than one Schedule 

### LE, add Line 

### 11 from each schedule, and write the total amount on Line 

### 12 ofthe last page. Also write this amount on Form RMFT-5-US, Lines 2b and 12; dyed diesel fuel, Column 

### 1; otherfuels, Column 2.



# '~

# - - 

# <J If 

## Jis Department of Revenue 

# Schedule SA MFT, i...:5T, and EIF Special Fuel (Excluding Dyed Diesel Fuel) Attach to Focm RMFT-5 ocFocm RMFT-5-US 

# Produced,Acquired, Received, orTransported into Illinois Page
__of
__ 

# Step 1: Complete the following information
Company name Check the tax/fee type you are listing on this page. 

## D MFT-free only Check the receipttype thatyou are listing on this page. 

## D Received in Illinois Your liconso number 

## O UST-!EIF-free only Reporting period
__ /
___ _ 

## O Both MFT- and UST-/EIF-free Month Year 

# Step 2: Reportyourtax- and fee-free purchases 1 lrwoice date (month, day, year} 

### 1 

# __ / 

### __) 

### ____ 

### 2 

### __)

### __ / 

### ____ 3 

# --'--'---- 4 __ /

### __ / 

### ____ 5 

### __ / 

### __ { 

### ____ 6 

# --'--'---- 7 

# --'--'---- 8 __ { 

# __ / 

# ____ 9 

## __t_J
____ 10

# __

# , __ / 

# ____ 2 Invoice number 

### 3 Nameof carrier 

### 4 Bill oflading or manifestnumber 

### 5 Name ofseller



### 11 Add the invoiced gallons in Column 9, Lines 1through 10, and write the total here. 6 Origin (city and state) 

## D Imported into Illinois 

## D Produced in your Jllinois refinery


### 7 Deslinalion (Illinois cities only) 

### 8 Seller's license number



### 11 

### 12 

### Jfyou are filing only one Schedule SA, write the amount from Line 11 here. 12 lfyou are reporting MFT-free gallons only, also write this amount on Form RMFT-5, Line 2a, Column 2. • UST-/EIF-free gallons only, also write this amount on Form RMFT-5-US, Line 2a, Column 1. • both MFT- and UST-/EIF-free gallons, also write this amount on Form RMFT-5, Line 2a, Column 2, and Form RMFT-5-US, Line 2a, Column 1. Ifyou are filing morethan one Schedule SA, see instructions. 1c,c

1 ,,c,cc,.c"'c"c'c"'c" 

## 0 c 

## 0 c,.c"c"c"c"'c 1 1r,=,"=~=,,.=eeca=1o=,c,,c.,cfoc,c~=m=,=,"=,c,.,c,c
.. 

## c"c""c"'c"7'"""""'"••"•,=,=,,=,=.=,c 0,c,

0 c, 

## 0 c"'c'

0 c 

## 0 c"c'"='="'°='=m,="=,,=,,=,c,c 0 cc,c

0 crn~I FRllure \u pruv,d~ lnformali()lo could re"ull mapetmlly. Thrs rorm has been apwoved by the Fmms Management Center. IL-492-1790 RMF"f'.6-SF front (R-12199) 

### 9 Invoiced gallons

# General Instructions Schedule SA is usedfor reporting the following taxes: Motor Fuel Tax (MFT) Underground StorageTank Tax (UST) Environmental Impact Fee (EIF) 

## Which special fuels must be reported on this schedule? The special fuels that must be reported on this schedule include diesel and anyother petroleum 

### products 

### (e.g., furnace oil, heating all, range oil, and kerosene) intended for use oroffered for sa!e as a fuel for engines in which the fuel is injected intothe combustion chamber and ignited 

### by pressure without electrlc spark.This does not include 1-K kerosene ordyed diesel fuel. Report dyed diesel fuel on Schedule DA, Form RMFi:6-0F. 

## When do I file this schedule? You mustfile Schedule SA with Form RMFT-5, Motor Fuel Distributor/SupplierTax Return, 

### ifyou are reporting MFT-free gallons only or both MFTand UST-/EIF-free gallons. You mustfile Schedule SAwith Form RMFT-5-US, Underground StorageTankTax and Environmental Impact Fee ReceiverTax Return, 

### ifyou are reporting only UST-/EIF-free gallons. 

## What must I attach to this schedule? You mustattach the credit invoices issued bythe seller
.We will return your credit invoices upon your request.



# - RMFT-6-SF bad 2/99) 

## What records must I keep? You are required by lawto keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What if I need additional assistance? lfyou have questions aboutthis schedule, write to us at Motor FuelTax, Illinois DepartmentofRevenue, P.O. Box 19477, Springfield, lllinois 62794-9477, or call ourSpringfield officeweekdays between 8 a.m. and 4:30 p.m. at 217 782-2291. 

# Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period for which you are reporting. Check the boxes nextto the tax/fee type and the receipt typeyou are listing on this page. Report onetax/fee type and one receipttype only per page. 

## Step 2: ReportyourtaxN and fee-free purchases Lines 

### 1through 

### 10- Column 1 - Write the month, day, and year ofthe invoice. Column 2 - Write the invoice number. Column 3 - Writethe carrier's complete business name. Column4 - Write the bill of lading or manifest number.**~** 

### Column 5 - Write the seller's complete name. Column 6 -Write the clty and the state (using the two-character U.S. Post Office abbreviation) from which the special fuel product originated. Column 7 -Write the name ofthe Illinois city to which the special fuel product was delivered. Column 8 - Write the seller's Illinois license number. Column 9 - Write the numberof invoiced gallons. Line 11 - Add the invoiced gallons reported in Column 9, Lines 1 through 10. Line 12- Ifyou arefiling morethan one Schedule SA, First, group together all Schedules SA that report UST-/EIF-free only gallons.Add Lines 11 from this group, and write the total on Line 12 ofthe last page. MFT-free only gallons.Add Lines 11 from this group, and write the total on Line 12 ofthe last page. both MFT- and UST-fEIF-free gallons. Add Lines 11 from this group, and write thetotal on Line 12 ofthe last page. Then, add the totalsfrom Lines 12 ofthe Schedules SAthat report MFT-free only gallons and both MFT- and UST-fEIF-free gallons and write this amounton Form RMFT-5, Line 2a, Column 2. UST-fEIF-free only gallons and both MFT- and UST-fEIF-free gallons and write this amount on Form RMFT-5-US, Line 2a, Column 1.



### t~

# rir 

# \)~c~o~c!R~!;',!:m~~us ::>is Department of Revenue 

# - IV1. - T, UST, and EIF Special Fuel (Excluding Dyed Diesel Fuel) Sold and Distributed Tax- and Fee-Free in Illinoisto Licensed Distributors or Suppliers 

## Step 1: Complete the following information**~** 

### Page
___of~-

Company name Check the tax/fee type you are listing on this page. 

## O MFT-free only Your license number Reporting period_ -'~
__ _ Month Year 

## Step2: Reportyourtax- and fee-free sales and distributions 1 Invoice date (month. day. year) 

### 1
__)
__ ,____ 

### 2 --'--'---- 

### 3
__)
__)
____ 4
__ /
__ /
____ 5 --'--'---- 

### 6
__ ! _ _)
____ 

### 7
__ /
__ /
____ 

### 8
__ / __)
____ 9
__ /
__ /
____ 

### 10
__)
__ /
____ 2 Invoice number 

### 3 Name of carrier 

### 4 Bill of lading or manifest number 

### 5 Name ofpurchaser 

### 6 Origin (Illinois cities only) 

## O UST-/EIF-free only 

## O Both MFT- and UST-/EIF-free



### 7 Destination (Illinois cities only) 

### 8 Purchaser's license number 

### 9 lrwoiced

11, "



### 11 Add the invoiced gallons in Column 9, Lines 1through 10, and write the total here. 11 ------~ 12 Ifyou are filing only one Schedule SD, write the amount from Line 11 here. 12
______ _ Ifyou are reporting MFT-free gallons only, also write this amount on Form RMFT-5, Line Ba, Column 2. • UST-/EIF-free gallons only, also write this amount on Form RMFT-5-US, Line 8, Column 1. • both MFT- and UST-/EIF-free gallons, also write this amount on Forms RMFT-5, Line Ba, Column 2, and RMFT-5-US, Line 8, Column 1. 

### Jfyou are filing more than one Sc.;h 0 e 

### 0 d 0 u 0 1ec:.'ScDc,c'cece,_..in 

### 0 s 0 

### t 0 ru

0 c 0 

### t 0 io



### 0 n 

### 0 s 0 .________________________ _ Tl11s form ,s oulhorrzed asou!lmed by Iha Motor FuolTa< Law and Ill& Envuorirnerrl"l lrnpac! FeeLaw. D.sclosuro ofUlls ,.,rormHIIOtl'" REQUIRED. Fa,1u,e to provide 1nfomoc,t1un could result mo per1ally.This form hasboon approved hy jt,~ Forr,,s M~""u<lrnenl Center ll-~~2·15~7 RMFT-32-SFfront(R-12/99)

# General Instructions Schedule SD is usedfor reporting the 

## following taxes: Motor Fuel Tax (MFT) Underground StorageTank Tax (UST) Environmental Impact Fee (EIF) 

## Which special fuels must be reported on this schedule? The special fuels that must be reported on this schedule include diesel and any other petroleum products 

### (e.g., furnace oil, heating oil, range oil, and kerosene) intended foruse oroffered for sale as 

### a fuel for engines in which the fuel is injected into the combustion chamber and ignited by 

### pressure without electric spark.This does not include 1-K kerosene ordyed diesel. Report your dyed diesel 

### fuel on Schedule DD, Form RMFT-32-DF. 

## When do Ifilethis schedule? You mustfile Schedule SD with Form RMFT-5, Motor Fuel 

### Distrlbutor/Supp!ierTax Return, ifyou are reporting MFT-free gallons only 

### or both MFTand UST-/EIF-free gallons. You mustfile Schedule SD with Form RMFT-5-US, Underground StorageTankTax and Environmental Impact Fee ReceiverTax Return, ifyou are reporting UST-/EIF-free gallons only. 

## What records must I keep? You are required by 

### law to keep books and records showing all purchases, receipts, losses through any cause, sales, distributions, and use of fuels. 

## What 

## if I need additional assistance? Ifyou have questions aboutthis schedule, write to us at Motor FuelTax, Illinois DepartmentofRevenue, 

### P.O. Box 

### 19477, Springfield, Illinois 

### 62794-9477, or cal! ourSpringfield officeweekdays between 

### 8 a.m. and 

### 4:30 p.m. at 217 782-2291. RMFT-32·SFb< ·12199) 

# Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number, and the period for

### which you are reporting. Check the boxes nextto the tax/fee type you are listing on this page. Report one tax/fee type per page. 

## Step 2: Report yourtax- and fee-free sales Lines 

### 1 through 

### 10

- Column 

### 1

- Write the month, day, and year ofthe invoice. Column 

### 2

- Write the invoice number. Column 3

- 

### Write the carrier's complete business name. Column

### 4

-Write the bill oflading or manifest number. Column 

### 5 -Write the purchaser's complete name. Column 

### 6 - Write the name ofthe Illinois city from which the special fuel product originated. Column 

### 7 - Write the name ofthe Illinois city to which the special fuel productwas delivered. Column 

### 8 -Write the purchaser's lllinois license number. Column 

### 9 - Write the numberof invoiced gallons. Line 

### 11

- Add the invoiced gallons reported in Column 9, Lines 1through 10.



# ' Line 

### 12

- Ifyou are filing morethan one Schedule SD: First, grouptogether all Schedules SD that report UST-/EIF-free only gallons. Add Lines 

### 11 from this group, and write the total on Line 12 

### ofthe last page. MFT-free only gallons. Add Lines 

### 11 from this group, and write the total on Line 

### 12 ofthe last page. both MFT- and UST-/EIF-free gallons.Add Lines 

### 11 from this group, and write the total on Line 

### 12 ofthe last page. Then, add the totals from Lines 

### 12 ofthe all Schedules SD that report UST-/EIF-free only gallons and both MFT- and UST-/EIF-free gallons and write this amount on Form RMFT-5-US, Line 8, Column 1. MFT-free only gallons and 

### both MFT- 

### and UST-/ EIF-free gallons and write this amounton Form RMFT-5, Line 

### 8a, Column 

### 2.



# ,')

# <J 11,..,ois Department of Revenue 

# Schedule SE Attach to Form RMFT-5 or Form RMFT-5-US 

### ~. 

# MFT, 1..JT, and EIF Tax- and Fee-Paid Purchases of Special Fuel (Excluding Dyed Diesel Fuel) Step 1: Complete the following information Page
__of
__

Check the lax/fee type you are listing on this page. Check llie product type you are listing on this page. Company name [] MFT-paid only Your l,cenoe number 

# r J UST-IEIF-paid only Reporting period I Monlh - 

### y,.;,, - [-] Bolh MFT- and UST-/EIF-paid 

## Step 2: Reportyourtax- and fee-paid purchases 1 2 3 4 Invoice date (•nonl11, rJay. year) 

### 1
__!
__ /
____ 

### 2 __ !
__ /
____ Invoice number Name of carrier Bill ofi;:1d1ng or manifestnumber 

### 5 Name ofseller 

## l 

## J Special fuel (excludin[I dyed diesel fuel) 

## ! I 1-1< kerosene 

## O Other (specify:
____ _


### 6 

### 7 8 Origin Destination Selle(s (Illinois cilies only) (Illinois cities only) license number



### 3 

### __ { 

### ______ I ----1------· 

### 4 _)
__ !
____ 

## -- --f---

- 5
_ _/
__ /
__ -- ·-+ -----"""""""""" 

### 6 - _!

__ /
__ -- 

### c------j----- 

# +-- t----- 

## !--

--- -- t -- 

# :

__; __; ____t- I 

# t 

# 1 I9
__I
__ /
____ 

### C---------+---------+-

--- --+- ·- ---- -- 

### 10
__ /
__ /____ I 

### 11 

### Add the invoiced gallons in Column 9, lines 1through 10, and write the total here. 

### 11 9 Invoiced gallons



### 12 Ifyou are filing only one Schedule SE, write the amountfrom Line 11 here. 12
____ _ Ifyou are reporting special fuel or other product type • MFT-paid gallons only, also write this amount on Form RMFT-5, Lines 2b and 17, Column 2. • UST-/EIF-paid gallons only, alsowrite this amount on Form RMFT-5-US, Lines 2b and 12, Column 1. • both MFT- and UST-/EIF-paid gallons, 8lso write this amount on Form RMFT-5, Lines 2b and 17, Column 2, and Form RMFT-5-US, lines 2b and 12, Column 1. Ifyou are reporting 1-K product type, write this amount on Form RMFT-5, line 17, Column 2. Ifyou are filing more than one 

### Schedule SE, see instructions. RMFT-10-SF fronl {R-3/01)

## General Instructions Schedule SE is usedfor reporting the 

## following taxes: Motor Fuel Tax (MFT) Underground StorageTankTax (UST) 

### Environmental Impact Fee (E!F) 

## Which transactions must be reported on this schedule? You must report any fuel transactions on which you have paid the motorfuel tax rate for special fuel. 

### UST/EIF paid gallons of 1-K kerosene must 

### also be reported on Schedule LE. 

## When do I 

## file this schedule? You must file Schedule SE with Form RMFT-5, Motor Fuel Distributor/SupplierTax Return, 

### ifyou are reporting MFT-paid gallons only or both MFTand UST-/E!F-paid gallons. You mustfile Schedule SE with Form RMFT-5-US, Underground StorageTank Tax and Environmental Impact Fee ReceiverTax Return, ifyou are reporting UST-/EIF-paid gallons on!y. 

## What records must I keep? You are required by law to keep books and records for at

### leastthree 

### and one-halfyears showing 

### all purchases, receipts, losses through any cause, sales, distributions, and use offuels. You must keep the original invoice for each taxand fee-paid purchase identified on Schedule SE. The invoice should be receipted "paid" and initialed by your supplier.You are not required to attach invoices to this schedule unless we request you to sendthem in. Ifwe do request your invoices toverify purchases, we will accept legible copies; however, we may require you send us the orlginals.



## --- --·-

## What 

## if l need additional assistance? Ifyou have questions aboutthis schedule, write to us at Motor FuelTax, Illinois Department ofRevenue, 

### P.O. Box 19477, Springfield, Illinois 62794-9477, or call ourSpringfield officeweekdays between 8 a.m. and 

### 4:30 p.m.at217 782-2291. 

## Step-by-Step Instructions Step 1: Complete the following information Write your company name, your license number. and the period for which you are reporting. Check the box nextto the tax/fee type and the product type you are listing on this page. Report one !ax/fee type and one producttype per page. 

## Step 2: Report your tax~ and fee~paid purchases Lines 

### 1 through 

### 10- Column 

### 1 - Write the month, day, ancl year of 

### the invoice. Column 

### 2 - Write the invoice number. Column 

### 3 - Write !he carr·ier's complete business name. Column 4 -Write the bill of lading or manifest number. Column 

### 5 -Write the seller's complete name. Column 

### 6
- Write the name ofthe Illinois city from which the special fuel product originated. Column 7 -Write the name ofthe !11inois city to which the special fuel productwas delivered. Column 8 -Write the seHer's Illinois license number. Column 9 - Write the numberof invoiced gallons. Line 

### 11

- Add the invoiced gallons reported in Column 

### 9, Lines 

### 1 through 

### 10. 

### Line 

### 12

- Ifyou are filing more than one Schedule SE, group togetherthe Schedules SE that report producttypes special fuel (excluding dyed diesel fuel) and other by MFT-paid only gallons. Add Lines 

### 11 from this group, and write the total on Line 12 of the last page. Also write this amount on Form RMFT-5. Line 2b, Column 2. UST~/EIF-paid only gallons. Add Lines 11 from !his group, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5-US, Line 2b, Column 1. both MFT- and UST~/EIF~paid gallons. Add Lines 

### i 1from lhls group, and write the total on Line 12 ofthe last page. Also write this amount on Form RMFT-5, Line 2b, Column 2. and Form RMFT-5-US, Line 2b, Colu111n 

### 1. Then, group together all Schedules SE that report UST-/EIF~paid only gallons and both MFT- and UST-/EIF-paid gallons. Add the totals from Lines 12, and write this amount on Form RMFT-5-US, Line 12, Column 1. Note: Do notinclude 1-K l(erosene in this total. MFT-paid only gallons and both

### MFT- and UST-/ EIF-paid gallons. Add the totals 

### from Lines 12, and write this amount on Form RMFT-5, Line 17, Column 2. Note: Include 

### ·1-K kerosene in this total.

RMFT-10-SF be-..,_3101) This fnm1 is ~ull10r,~"d as ~,i11w,11>y tlLo r.io,~, FLJol fax I.aw ai,rl 111~ (.ll'!>tt>t>tMt1t,il hnpaU**~~e** L.,., LJ,,,.,1"··""' ~( I'"" 1r:1<,rn1a~0n ,s HlDUIHLIJ r~,1,1ra lo P"'"'·IP ml"'"'"""~n~ld_,,,,,Llll_,"_'01'""•'.!.ILT.!.'!':._l"<>I_Hl_h_.,, 1,·-p1H·~,,,11,y~·~l,!!'""'l.''""'"I C_@IPr ll·lfl."-101:S

## ~~