Form PT-16 Pull Tabs and Jar Games Supplier's Quarterly Report - Illinois

Form PT-16 or the "Pull Tabs And Jar Games Supplier's Quarterly Report" is a form issued by the Illinois Department of Revenue.

The form was last revised in August 1, 2015 and is available for digital filing. Download an up-to-date Form PT-16 in PDF-format down below or look it up on the Illinois Department of Revenue Forms website.

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Illinois Department of Revenue
PT-16
Pull Tabs and Jar Games Supplier’s Quarterly Report
Read this information first
For each sale or delivery of pull tabs, you must give a receipt
This report must be signed and dated by a responsible
to your purchaser. Each receipt must include
officer of your organization within 30 days after the end of
the date of sale or delivery;
the calendar quarter. You no longer have to submit the report
your name and license number;
to us. Keep the completed copy in your records and make it
the name and license number of the pull tabs purchaser;
available to us when we request it. Failure to comply will result
the name of the pull tabs manufacturer; and
in actions against your license up to and including revocation.
the serial number and ideal gross receipts for each
If you have questions, visit our website at tax.illinois.gov or
game.
call us at 217 785-5864.
You must maintain all records related for a period of three
years.
Step 1: Identify your business
PS –
Business name
Pull tabs supplier’s license no.
_________________________________________
_____________________
Mailing address
For the quarter ending
_________________________________________
______/______/______
Number and street
Month
Day
Year
_______________________________________________________
City
State
ZIP
Step 2: Complete the following information
Did you sell or deliver pull tabs to persons or organizations located in Illinois during this reporting period?
yes
no
If “yes,” attach to this report a copy of each receipt as described in “Read this information first” and initial the statement below.
______ Receipts attached to this report reflect all pull tabs sold or delivered to persons or organizations located in Illinois during
this reporting period.
If “no,” initial the statement below.
______ No pull tabs were sold or delivered to persons or organizations located in Illinois during this reporting period.
Step 3: Sign below
Under penalties of perjury, I state that I have examined this report and, to the best of my knowledge, it is true, correct, and
complete. I further certify that the information contained in this report is taken from the records of the organization for which it is
filed and that no other sales, authorized or unauthorized, were made during the quarter covered by this report.
_______________________________________________________
Responsible party’s signature
_______________________________________________________
Title
_______________________________________________________
Date
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this
information is required. Failure to provide information may result in this form not being processed and may result in a penalty.
PT-16 (R-08/15)
Reset
Print
Illinois Department of Revenue
PT-16
Pull Tabs and Jar Games Supplier’s Quarterly Report
Read this information first
For each sale or delivery of pull tabs, you must give a receipt
This report must be signed and dated by a responsible
to your purchaser. Each receipt must include
officer of your organization within 30 days after the end of
the date of sale or delivery;
the calendar quarter. You no longer have to submit the report
your name and license number;
to us. Keep the completed copy in your records and make it
the name and license number of the pull tabs purchaser;
available to us when we request it. Failure to comply will result
the name of the pull tabs manufacturer; and
in actions against your license up to and including revocation.
the serial number and ideal gross receipts for each
If you have questions, visit our website at tax.illinois.gov or
game.
call us at 217 785-5864.
You must maintain all records related for a period of three
years.
Step 1: Identify your business
PS –
Business name
Pull tabs supplier’s license no.
_________________________________________
_____________________
Mailing address
For the quarter ending
_________________________________________
______/______/______
Number and street
Month
Day
Year
_______________________________________________________
City
State
ZIP
Step 2: Complete the following information
Did you sell or deliver pull tabs to persons or organizations located in Illinois during this reporting period?
yes
no
If “yes,” attach to this report a copy of each receipt as described in “Read this information first” and initial the statement below.
______ Receipts attached to this report reflect all pull tabs sold or delivered to persons or organizations located in Illinois during
this reporting period.
If “no,” initial the statement below.
______ No pull tabs were sold or delivered to persons or organizations located in Illinois during this reporting period.
Step 3: Sign below
Under penalties of perjury, I state that I have examined this report and, to the best of my knowledge, it is true, correct, and
complete. I further certify that the information contained in this report is taken from the records of the organization for which it is
filed and that no other sales, authorized or unauthorized, were made during the quarter covered by this report.
_______________________________________________________
Responsible party’s signature
_______________________________________________________
Title
_______________________________________________________
Date
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this
information is required. Failure to provide information may result in this form not being processed and may result in a penalty.
PT-16 (R-08/15)
Reset
Print
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