ILLINOIS DEPARTMENT OF REVENUE 

                    DRAFT FORM 

Note: The draft you are looking for begins on the next page. 

Caution: DRAFT—NOT FOR FILING 

This is an early release draft of an Illinois Department of Revenue (IDOR) tax form or instructions, which 
IDOR is providing for substitute forms providers. Do not file draft forms and do not rely on draft forms 
and instructions for filing. We incorporate all significant changes to forms posted with this coversheet. 
However, unexpected issues occasionally arise, or legislation is passed—in this case, we will post a new 
draft of the form to alert users that changes were made to the previously posted draft.  

All forms and instructions have a page on our website at Tax Forms (illinois.gov) where you may see the 
final versions once they are released. Year-end income tax forms are usually released towards the end 
of January. 

If you wish, you can submit comments and questions to IDOR about draft or final forms and instructions 
at REV.VendorForms@illinois.gov. We will forward this information to the Office of Publications 
Management, where forms and publications are administered. 

IDR-1-DIS (N-08/23)          Printed by authority of State of Illinois, web only – one copy. 
 

                    TENTATIVE FINAL

         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 - electronic only - one copy.

        Illinois Department of Revenue                                       Payment Voucher for 
                                                                         Amended Fiduciary                                     
        IL-1041-X-V  IL-1041-X-V(R-12/23)                                    Income and Replacement Tax
                                                                                                                                   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:   (                        )                                                                              *64512231V*