Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.

           To pay the amount you owe, complete the following steps:

           1  Enter your federal employer identification number (FEIN).

           2  Enter your name, C/O information (if applicable), address, and phone number.

           3  Enter the month and year your tax year ends.

           4  Enter the amount you are paying. Use whole dollars only.

           5  Detach the voucher and enclose a check or money order for the amount you are paying. 
                    •  Write your FEIN, tax year ending, and “IL-1041-X-V” on your payment. 
                    •  Make your check or money order payable to “Illinois Department of Revenue.” 
                    •  Attach your completed voucher and payment to your amended return, and mail them                                                                                     
                      to the address shown on the voucher. 

           Printed by the authority of the State of Illinois - web only - one copy.
           Illinois Department of Revenue                                             Payment Voucher for 
                                                                                  Amended Fiduciary                                               
       2022 IL-1041-X-V                                                               Income and Replacement Tax
                          IL-1041-X-V (R-12/22)                                                                                                     Official use only
                          Mail to: Illinois Department of Revenue, P.O. Box 19016, Springfield, IL  62794-9016
                 If no             payment is due or you make your payment electronically, do not file this form.
                                                                                                                                    Tax year ending
  FEIN:                                                                                                                                 
                                                                                                                                                                   
  Name:                                                                                                                             Month           Year
                                                                                                                                                    
  C/O:                                                                                                                      $                               00
  Mailing                                                                                                               Payment   Amount (Whole    dollars  only)   
  address:                                                                                                           Write your FEIN, tax year ending, and “IL-1041-X-V” on your check or 
                                                                                                                     money order and make it payable to “Illinois Department of Revenue.”
  City:                                                                        State:                      ZIP:

  Phone:    (                       )                                                                                               *64512221W*
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