Form PA-1 State Cigarette P.a.c.t. Act Report - Illinois

Form PA-1 or the "State Cigarette P.a.c.t. Act Report" is a form issued by the Illinois Department of Revenue.

The form was last revised in May 1, 2014 and is available for digital filing. Download an up-to-date Form PA-1 in PDF-format down below or look it up on the Illinois Department of Revenue Forms website.

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PA- 1
State Cigarette P.A.C.T. Act Report
Step 1: Identify your business
Name:
Reporting period: __ __/__ __ __ __
_________________________________________________
(Month/Year)
Address:
License no.: ____________________________
_______________________________________________
Number and street
Federal employer identification number:____-______________
_______________________________________________________
City
State/Province
ZIP
(FEIN)
Country/Territory: ___________________________________
Phone: (_____)______- ___________ Ext:__________
Contact name: ______________________________________
Email address:___________________________________
Step 2: Identify your sales into Illinois
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
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 also
state that such information is taken from the books and records of the business for which this report is filed.
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Owner or officer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Preparer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
PA-1 (R-05/14)
PA- 1
State Cigarette P.A.C.T. Act Report
Step 1: Identify your business
Name:
Reporting period: __ __/__ __ __ __
_________________________________________________
(Month/Year)
Address:
License no.: ____________________________
_______________________________________________
Number and street
Federal employer identification number:____-______________
_______________________________________________________
City
State/Province
ZIP
(FEIN)
Country/Territory: ___________________________________
Phone: (_____)______- ___________ Ext:__________
Contact name: ______________________________________
Email address:___________________________________
Step 2: Identify your sales into Illinois
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Cigarettes (sticks):________________________
Brand:_____________________________ UPC: ___________________________________________
Sale price: $_______________________________
Buyer: _____________________________ Address:________________________________________
FEIN: ________________ License #:___________
Street address
City
State
ZIP
Deliverer: __________________________ Address:________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
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 also
state that such information is taken from the books and records of the business for which this report is filed.
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Owner or officer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Preparer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
PA-1 (R-05/14)
General Information
Step-by-Step Instructions
What does the P.A.C.T. Act refer to?
Step 1: Identify your business
The Prevent All Cigarette Trafficking Act of 2009 was enacted
License number – write the license number issued to you by
by Congress and is commonly referred to as the PACT Act.
the Department. If you do not have a license number, write
S. 1147 was signed into law on March 31, 2010 as Public Law
your federal employer identification number(FEIN).
111-154.
Step 2: Identify your sales
It is the purpose of this Act to:
UPC – write the UPC carton code.
• require Internet and other remote sellers of cigarettes
FEIN or License # – write the federal employer identification
and smokeless tobacco to comply with the same laws
number (or federal identification number FTIN). If the buyer
that apply to law-abiding tobacco retailers;
does not have either of these numbers, write the buyer's state
• create strong disincentives to illegal smuggling of
cigarette license number. If you are making a delivery sale to
tobacco products;
a consumer, leave this line blank.
• provide government enforcement officials with more
Deliverer name, address and phone – complete only for
effective enforcement tools to combat tobacco
delivery sales and provide the information of the person who
smuggling;
delivered the cigarettes for you.
• make it more difficult for cigarette and smokeless
tobacco traffickers to engage in and profit from their
illegal activities;
• increase collections of Federal, State, and local excise
taxes on cigarettes and smokeless tobacco; and,
• prevent and reduce youth access to inexpensive
cigarettes and smokeless tobacco through illegal
Internet or contraband sales.
Who must file this report?
You must file this report if you sell, transfer, or ship (for profit)
cigarettes into Illinois to a person other than a distributor
licensed or located in Illinois.
When do I file?
The report is due no later than the 10
th
day of each calendar
month for the previous calendar month's shipments.
Where do I send the report?
A separate report should be sent to the cigarette tax
administrator of each state into which shipments are made.
Mail to: Illinois Department of Revenue
P.O. Box 19477
Springfield IL 62794-9477
PA-1 (R-05/14)

Download Form PA-1 State Cigarette P.a.c.t. Act Report - Illinois

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