Form RCOA-1-A Coin-Operated Amusement Device Schedule - Illinois

Form RCOA-1-A is a Illinois Department of Revenue form also known as the "Coin-operated Amusement Device Schedule". The latest edition of the form was released in April 1, 2010 and is available for digital filing.

Download a PDF version of the Form RCOA-1-A down below or find it on Illinois Department of Revenue Forms website.

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Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
Illinois Department of Revenue
RCOA-1-A
Coin-Operated Amusement Device Schedule
Page _____ of _____
Read this information first
You must complete and attach this schedule to your completed Form RCOA-1, Coin-Operated Amusement Device Tax Decal Order Form.
If you are ordering more decals than provided for on this schedule, make additional copies of this schedule. If you wish to submit a
computer-generated version, you must first obtain our approval of your format.
We cannot issue a decal until Columns A through D are completed for each machine for which you are ordering decals. Failure to attach
a completed schedule to Form RCOA-1 may result in a penalty and seizure of unlicensed machines.
Step 1:
Identify your business
1
2
Name: ______________________________________________________
Date:__ __ /__ __ /__ __ __ __
3
4
Account ID: ___ ___ ___ ___ ___ ___ ___ ___
License no. : AD - ___ ___ ___ ___ ___
Step 2:
Identify each machine and its location
Machine code required for Column A:
8a
8b
8c
Jukeboxes
Mechanical rides
Pinballs
8d
8e
8f
Pool games
Redemption machines
Shuffleboards
8g
8h
8i
Video games - amusement
Video games - simulated gaming
Other
A
B
C
D
C
ode
Machine serial no.
Display/operation date
Complete address where machine will be displayed
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
*048501110*
Official Use - Do not write below this line
RCOA-1A front (R-04/10)
Batch no. of RCOA-1: ______________________________ Confirmation number: _______________________________
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
Illinois Department of Revenue
RCOA-1-A
Coin-Operated Amusement Device Schedule
Page _____ of _____
Read this information first
You must complete and attach this schedule to your completed Form RCOA-1, Coin-Operated Amusement Device Tax Decal Order Form.
If you are ordering more decals than provided for on this schedule, make additional copies of this schedule. If you wish to submit a
computer-generated version, you must first obtain our approval of your format.
We cannot issue a decal until Columns A through D are completed for each machine for which you are ordering decals. Failure to attach
a completed schedule to Form RCOA-1 may result in a penalty and seizure of unlicensed machines.
Step 1:
Identify your business
1
2
Name: ______________________________________________________
Date:__ __ /__ __ /__ __ __ __
3
4
Account ID: ___ ___ ___ ___ ___ ___ ___ ___
License no. : AD - ___ ___ ___ ___ ___
Step 2:
Identify each machine and its location
Machine code required for Column A:
8a
8b
8c
Jukeboxes
Mechanical rides
Pinballs
8d
8e
8f
Pool games
Redemption machines
Shuffleboards
8g
8h
8i
Video games - amusement
Video games - simulated gaming
Other
A
B
C
D
C
ode
Machine serial no.
Display/operation date
Complete address where machine will be displayed
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
*048501110*
Official Use - Do not write below this line
RCOA-1A front (R-04/10)
Batch no. of RCOA-1: ______________________________ Confirmation number: _______________________________
*048502110*
Step 2:
Identify each machine and its location
(continued)
Machine code required for Column A:
8a
8b
8c
Jukeboxes
Mechanical rides
Pinballs
8d
8e
8f
Pool games
Redemption machines
Shuffleboards
8g
8h
8i
Video games - amusement
Video games - simulated gaming
Other
A
B
C
D
C
ode
Machine serial no.
Display/operation date
Complete address where machine will be displayed
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
8____
______________
________________________________________________
__ __ /__ __ /__ __ __ __
Street address
City
ZIP
RCOA-1A back (R-04/10)
This form is authorized as outlined by the Coin-Operated Amusement Device and Redemption Machine Tax Act. Disclosure of this information is
REQUIRED. Failure to provide information could result in penalties. This form has been approved by the Forms Management Center. IL-492-0023
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