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    Illinois Department of Revenue
    Request for Transfer of Credit Memorandum

                                                                                                                   OFFICIAL USE ONLY
The fi ling of this form is required by the Illinois Department of Revenue in order to transfer a Credit                  License Number
Memorandum to a registration number other than that to which the credit was originally issued.

                                             SECTION I — Credit Memorandum To Be Transferred
 1  Business name                                                                                       7  Credit Memorandum number

 2  Owner(s), corporate name if owner is a corporation                                                  8  License number

 3  Number and street address                                                                           9  Date Credit Memorandum issued

 4  City                                     5  State      6    ZIP code                                10 Amount of Credit Memorandum

              SECTION II — Transfer Credit Memorandum To                                                           OFFICIAL USE ONLY
 11 License number
                                                                                                           LIC.
                                                                                                           NO.
 12 Business name     
                                                                                                           LOC.
                                                                                                           CODE:
 13 Owner(s), corporate name if owner is a corporation                                                     CREDIT
                                                                                                           MEMO
                                                                                                           NO.:
 14 Number and street address                                
                                                                                                           DATE
                                                                                                           ISSUED
 
15  City                                     16 State      17   ZIP code 
                                                                                                           AMOUNT $

                                                SECTION III — Signature Affi davit of Seller
                                To be completed by the business in whose name the Credit Memorandum was originally issued.
                                PROPRIETORSHIP OR PARTNERSHIP - Line 18; CORPORATION - Lines 19 & 20

                                                                                                           Mail Excise Tax requests to:
 I realize that the Illinois Department of Revenue must apply the attached Credit Memorandum to 
 any outstanding liability I might have. The remaining balance, if any, will then be transferred.
                                                                                                           EXCISE TAXES DIVISION
                                                                                                           ILLINOIS DEPARTMENT OF REVENUE
 18                                                                                                        PO BOX 19477
         Signature of owner or partner                          date                                       SPRINGFIELD IL  62794-9477

 19
         Signature of officer of corporation                     date

 20
         Title

    This form is authorized as outlined by the Retailer's Occupation Tax and Related Tax Acts. 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-492-1370
                                                                                                                   *091601110*
         RCR-16 (R-04/10)
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