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     Illinois Department of Revenue

  ETS-33                    Application for

                            Duplicate Credit Memorandum

Step 1:  Identify your business 

License number  _______________________                    Account ID  _______________________ 

Name            _________________________________________________________________________________________

Address         _________________________________________________________________________________________

City, State, ZIP _________________________________________________________________________________________

Step 2:  Identify the requestor

Name of person or firm making this request  __________________________________________________________________
                                          Please print
 
Title (if corporation)  _____________________________________________________________________________________

Step 3:  Credit memorandum to be transferred (to be completed by Department personnel)

Original credit memo:                                      Reissued credit memo:

Letter ID                    _______________________  Letter ID                                                                                   _______________________

Date on original credit memo __ __ / __ __ / __ __ __ __  Date on reissued credit memo  __ __ / __ __ / __ __ __ __
                                    Month Day         Year                                                                                             Month Day Year
 
Original credit memo amount  $_______________________  Reissued credit memo amount   $_______________________

Step 4:  Sign below

I state that the original credit memorandum shown above and issued by the Illinois Department of Revenue has been 
misplaced, lost, or destroyed, thereby preventing the use of all or part of the amount either to pay any current or future taxes 
due the Department or to transfer to another account.

Signature  ________________________________________________________________  Date______________________

Step 5:  Mail the form

Mail this completed form to:

ALCOHOL TOBACCO AND FUEL DIVISION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19019
SPRINGFIELD IL  62794-9019

For questions, visit our website at tax.illinois.gov or call us weekdays between 8 a.m. and 4:30 p.m. at 217 782-6045.

                 This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this 
                 information is required. Failure to provide information may result in this form not being processed and may result in a penalty. 
ETS-33 (R-02/16)
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