Use your 'Mouse' or the 'Tab key' to move through the fields and 'Mouse' or 'Space bar' to enable the checkboxes.

       Illinois Department of Revenue
       Receipt for Qualified K-12 Education Expenses
       To be completed by school personnel and distributed to parents or guardians                                                                                                                    Calendar year  
Read this information first 
Recipients:  Do not attach this receipt to your Form IL-1040, Individual Income Tax Return.  Keep this receipt with your income 
        tax records.  You must send us this information if we request it.  
          To figure the amount of your education credit, you must complete Schedule ICR, Illinois Credits.

Step 1:
Payments received from:                                                                                                           Payments paid to:  
                       Name of parent or guardian                                                                                                                     Name of school

                       Social Security number of parent or guardian                                                                                                   Address of school
                       (This required information may be provided by the recipient)

                                                                                                                                                                      City, State, ZIP of school
Step 2:  To be completed by authorized school personnel
Complete the table below.  For column G, provide only the amount of qualified expenses paid to the school by the parent or guardian 
named in Step 1 during the calendar year indicated at the top of this form.  See Publication 112 for a list of qualified expenses.
Do not include any amounts paid by scholarship, grant, or another entity.  Also, do not include any balances not paid during the 
calendar year.     
         A                          B                                                                          C                D                                   E                        F                        G  
    Name of Student         Social Security number                                                          Grade           Qualified                               Qualified                Qualified     Total Amount of 
                         (This required information may be                                                  (K-12 only)                      Tuition Book Fees                Lab Fees           Qualified Expenses        
                            provided by the recipient)                                                                            Paid                              Paid                     Paid          Paid by Parent 
                                                                                                                                                                                                           or Guardian 

  1                          -          -                                                                                       $                                 $                        $                       $

  2                          -          -                                                                               $                                         $                        $                         $

  3                          -          -                                                                               $                                         $                        $                         $

  4                          -          -                                                                               $                                         $                        $                         $

                                                                                                                         $                           $                        $                            $
  5                          -          - 
   Add the amounts in the “Total Amount of Qualified Expenses Paid by Parent or Guardian” column  for each student. 
   Use this total to complete the K-12 Education Expense Credit Worksheet on Schedule ICR.                                                                                                    Total       $

    Step 3: Signature of authorized school personnel
  I state that I have prepared this receipt and, to the best of my knowledge, it is true, correct, and complete.

       Name                                           Signature                                                                                                               Date
                                                      (         )  
       Title                                          Phone Number                                                                                                  This form is authorized as outlined under the Illinois Income 
                                                                                                                                                                         Tax Act.  Disclosure of this information is required.  
                                                                                                                                                                         Failure to provide information could result in a penalty.
IL-1040-Rcpt (R-04/18)                      Printed by authority of the State of Illinois - Web only

                                                      Reset                                                                       Print