Form PT-12 Expenditures of Pull Tab Funds - Illinois

Form PT-12 is a Illinois Department of Revenue form also known as the "Expenditures Of Pull Tab Funds". The latest edition of the form was released in August 1, 2015 and is available for digital filing.

Download an up-to-date Form PT-12 in PDF-format down below or look it up on the Illinois Department of Revenue Forms website.

Step-by-step Form 12 instructions can be downloaded by clicking this link.

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Use your 'Mouse' or the 'Tab key' to move through the fields and 'Mouse' or 'Space bar' to enable the checkboxes.
Illinois Department of Revenue
PT-12
Expenditures of Pull Tab Funds
Step 1: Identify yourself
Name ____________________________________________
Reporting period: From ____/_____/____ To ____/____/____
month
day
year
month
day
year
Address __________________________________________
Pull Tab License P-___________
_________________________________________________
Telephone no. (_____) ______-__________
Step 2: Figure your pull tab proceeds
1 Gross proceeds from pull tabs during reporting period
1 ____________________________
2 Cash prizes awarded
2 ____________________________
3 Subtract Line 2 from Line 1. Net proceeds (deposited in pull tab checking account)
3 ____________________________
4 Other deposits in pull tab checking account
4 ____________________________
5 Balance in pull tab checking account at start of reporting period
5 ____________________________
6 Add Lines 3, 4, and 5
6 ____________________________
7 Dollar amount of all checks written on pull tab checking account and all other
charges to pull tab checking account during reporting period
7 ____________________________
8 Subtract Line 7 from Line 6
8 ____________________________
9 Balance in pull tab checking account at end of reporting period
9 ____________________________
Line 9 should equal Line 8. If the amounts are not identical, please explain the discrepancy here:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Step 3: List your checks and charges -
Enter in sequential order and attach additional sheets if necessary.
_____________________________________________________________________________________________________
Check number
Amount
Person or organization
Purpose
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Continue on the next page.
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-12 front (R-08/15)
Use your 'Mouse' or the 'Tab key' to move through the fields and 'Mouse' or 'Space bar' to enable the checkboxes.
Illinois Department of Revenue
PT-12
Expenditures of Pull Tab Funds
Step 1: Identify yourself
Name ____________________________________________
Reporting period: From ____/_____/____ To ____/____/____
month
day
year
month
day
year
Address __________________________________________
Pull Tab License P-___________
_________________________________________________
Telephone no. (_____) ______-__________
Step 2: Figure your pull tab proceeds
1 Gross proceeds from pull tabs during reporting period
1 ____________________________
2 Cash prizes awarded
2 ____________________________
3 Subtract Line 2 from Line 1. Net proceeds (deposited in pull tab checking account)
3 ____________________________
4 Other deposits in pull tab checking account
4 ____________________________
5 Balance in pull tab checking account at start of reporting period
5 ____________________________
6 Add Lines 3, 4, and 5
6 ____________________________
7 Dollar amount of all checks written on pull tab checking account and all other
charges to pull tab checking account during reporting period
7 ____________________________
8 Subtract Line 7 from Line 6
8 ____________________________
9 Balance in pull tab checking account at end of reporting period
9 ____________________________
Line 9 should equal Line 8. If the amounts are not identical, please explain the discrepancy here:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Step 3: List your checks and charges -
Enter in sequential order and attach additional sheets if necessary.
_____________________________________________________________________________________________________
Check number
Amount
Person or organization
Purpose
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Continue on the next page.
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-12 front (R-08/15)
Step 4: Provide your financial institution information
Provide the name and address of the financial institution where your pull tab checking account is maintained.
Financial institution: _________________________________
_________________________________________________
Name
Address
Your account number ___________________________________________________________________________________
List persons authorized to make expenditures from your pull tab checking account. (Attach additional sheet if necessary)
_________________________________________________
_________________________________________________
Name
Address
_________________________________________________
_________________________________________________
Name
Address
Reset
Print
PT-12 back (R-08/15)

Download Form PT-12 Expenditures of Pull Tab Funds - Illinois

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