Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
      Illinois Department of Revenue
                                                            Claim for Refund
      IDR-277-C                       Single Trip Interstate Motor Fuel Use Tax Permit

Who should fi le this form?
Approved permit providers must complete Form IDR-277-C to receive a refund for voided Single Trip Interstate Motor Fuel Use Tax Permits 
returned to the Illinois Department of Revenue. A separate claim must be fi led for each permit that has been returned.
Where do I send my completed Form IDR-277-C?
Mail your completed Form IDR-277-C and voided permit to  
                    ILLINOIS DEPARTMENT OF REVENUE
                    PO BOX 19018
                    SPRINGFIELD IL  62794-9018

Step 1: Identify your business
Account ID: __ __ __ __ __ __ __ __                           

License no.: ST - __ __ __ __ __                              
Name:   _______________________________________________
Address: _______________________________________________   
City:______________________________   ZIP:________________   

Step 2: Check all that apply to the reason you are completing this claim 
1 _____ Typed the wrong information on the permit.
2 _____  Discovered the driver did not need permit after it was issued. 
3 _____ Issued for incorrect state or agency.
4 _____ Other - Describe the situation. Attach additional sheets if needed.
        ________________________________________________________________________________________________________
        ________________________________________________________________________________________________________
        ________________________________________________________________________________________________________
        ________________________________________________________________________________________________________
        ________________________________________________________________________________________________________

Step 3: Figure your claim amount
5 Write the voided permit number:___________________________
  You must attach it to this claim.

6 Permit fee to be refunded:   $40.00 

Step 4: Sign below  
I certify that, to the best of my knowledge, the information on this claim for refund is true and accurate and that I am seeking a refund for   
payment of a permit that was never issued, but was voided for the reason indicated above.
         _______________________________________________  ___ ___/___ ___/___ ___ ___ ___                                                                  Offi cial Use
        Signature                                                       Date                                                                   No    ____________
                                                                                                                                               Amt   ____________
                                                                                                                                               Apv   ____________
                                                                                                                                               Vrf   ____________
*092201110*                                                                                                                                    DR    ____________
                                                                                                                                               Int D ____________

                                   IDR-277-C (R-04/10)
                                   This form is authorized by the Motor Fuel Tax Law. Disclosure of information is REQUIRED. Failure to comply 
                                   may result in a penalty. This form has been approved by the Forms Management Center.  IL-492-4593
                                                      Reset             Print