STATUS [ ] LIQUOR TAX Number of Sites: Page 1 DEPARTMENT OF REVENUE CITY OF CHICAGO

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1 ITY OF HIGO EPRTMENT OF REVENUE LIQUOR TX STTUS [ ] For office use only Mail Payment and Return to: OUNT NUMER UE TE HEK IF RETURN IS: Number of Sites: mended EGINNING PERIO ENING PERIO USINESS PHONE MILING RESS: USINESS RESS: heck the following if deposits were: Estimate ctual (If actual, annualization schedule must be attached) If you have any changes to the account information listed on this return please contact lient onsultation of the epartment of Revenue at (312) 747-IRIS (4747). o not fill in cents amount, round up to nearest dollar (if 50 cents or more). eer Inventory of all alcoholic beverages at the beginning of the period... lcoholic beverages added to inventory (line 2d of instructions)... lcoholic beverages available for sale (add lines 1 and 2) Inventory of all alcoholic beverages at the end of the period... lcoholic beverages removed from inventory (subtract line 4 from line 3)... Page

2 OUNT NUMER REVISION NUMER eer 6. eductions (line 6g of instructions) Total alcoholic beverages subject to tax (subtract line 6 from line 5) pplicable tax rates per gallon omputed tax for each column (multiply line 7 by line 8). 10. Tax due before current year's tax payments (add lines 9a through 9d) urrent year's tax payments Total tax due (subtract line 11 from line 10). If line 12 is greater than 0, enter the amount owed. If line 12 is less than 0, skip to line Interest due for late payment (line 13c of instructions ) Penalty for late payment/filing (see instructions)... Page

3 OUNT NUMER REVISION NUMER MRKING INSTRUTIONS Use a black or blue ink pen only. o not use pens with ink that soaks through the paper. Print clearly, using all PITL letters. 15. Total tax, interest, and penalty due (add lines 12, 13, and 14) Overpayment. If line 12 is less than 0, enter the amount of overpayment If you want the amount ofthe overpayment to be credited to next year's estimated tax, enter a check in the credit box. Otherwise, check the refund box. redit Refund NOTE: ny amounts overpaid will first be applied to deficiencies outstanding for this tax and to deficiencies for any other ity of hicago tax for which you are registered. Owner/Officer Statement Under penalty of perjury, I certify that I have examined this return, and to the best of my knowledge and belief, it is true, correct and complete. FIRST NME LST NME PHONE NUMER TE SIGNTURE (REQUIRE) TITLE Preparer Statement Under penalty of perjury, I certify that I have examined this return, and to the best of my knowledge and belief, it is true, correct and complete. FIRST NME LST NME PHONE NUMER TE GENT/PI PREPRER SIGNTURE (REQUIRE) PHONE USINESS NME F.E.I.N. NOTE: YOU MUST FILL THIS FORM OUT OMPLETELY. IF NY INFORMTION IS OMITTE, THIS RETURN WILL E EEME INOMPLETE, N YOU WILL E SSESSE ITIONL PENLTIES. OUNT NUMER MUST E ENTERE. For OR Use Only Postmark ate Receipt Number Page

4 1. 2. a. b. c. d OUNT NUMER INSTRUTIONS FOR PREPRING THE LIQUOR TX RETURN LINES 1 THROUGH 7 MUST E ROUNE TO WHOLE GLLONS. When calculating the amount of gallons, round up to the nearest whole gallon if the quantity is 0.5 or more. Round down to the nearest whole gallon if the quantity is 0.49 or less. Enter the amount of alcoholic beverages held in beginning inventory on the first day of the period. This amount includes any and all alcoholic beverages owned by your business, regardless of location... eer Enter the amount of alcoholic beverages added to inventory during the period: Manufactured, rectified, distilled, blended or bottled... Purchased in original containers... Merchandise returned from retailers in a condition suitable for subsequent sale... Total additions to alcoholic beverage inventory during the period (add lines 2a through 2c)... Enter the total amount of alcoholic beverages available for sale during the period (add lines 1 and 2)... Enter the amount of alcoholic beverages held in ending inventory on the last day of the current period. This amount includes any and all alcoholic beverages owned by your business, regardless of location... Enter the total amount of alcoholic beverages sold, used, or otherwise removed from inventory (subtract line 4 from line 3)... Page

5 6. a. b. c. d. e. f. g. 7. OUNT NUMER Enter the deductions as listed below (if applicable): lcoholic beverages sold to interstate carriers for resale aboard the carrier... When sold to religious organizations and used for sacramental purposes... lcoholic beverages sold to other wholesale dealers where no tax has been paid... lcoholic beverages rendered unsaleable due to breakage or spoilage... lcoholic beverages sold to retailers located outside the ity of hicago... lcoholic beverages returned from retailers on which you credited or refunded hicago Liquor Tax... Total deductions (add lines 6a through 6f)... Enter the amount of alcoholic beverages subject to tax (subtract line 6 from line 5)... Page 2 eer

6 OUNT NUMER Line 8. Line 9. Line 10. Line 11. Line 12. Line a. Preprinted tax rate. omputed tax for each column (multiply line 7 by line 8). Tax due before current year's tax payments (add fields 9a through 9d). Enter the total amount of all of the current year's tax payment you have remitted to the hicago epartment of Revenue. Enter total tax due (subtract line 11 from line 10). If line 12 is greater than 0, enter amount owed. If line 12 is less than 0, skip to line 16. etermine the amount of interest owed based on tax past due. Enter number of days late (ugust 16 being one day late, etc.)... 13b. Enter the amount from line c. Total amount of interest (13b * [13a / 365]) * 12%... EXMPLE: If you determine that you owe $100,000 on the due date (ugust 15) and you file and pay the tax on ugust 26, then you are 11 days late in making the payment. The calculation of the interest owed is as follows: [$100,000 * (11/365)] * 12% = $ Line 14. Line 15. Line 16. Line 17. Late penalties: ompute penalty based on 1 of the 2 requirements listed below: a) if the return is being filed timely, but payment is late, compute 5% of line 12 b) If the return is filed late, compute the greater of 1) 1% of line 10 (up to a maximum of $5,000) or 2) 5% of line 12 The tax return is due on or before the 15th day of the second month following the fiscal year in which taxable receipts are received. Enter the total tax, interest, and penalty due (add lines 12, 13, and 14). Overpayment. If line 12 is less than 0, enter the amount of overpayment. If you want the amount of the overpayment to be credited to next year's estimated tax, enter a check in the credit box. Otherwise, check the refund box. NOTE: ny amounts overpaid will first be applied to deficiencies outstanding for this tax and to deficiencies for any other ity of hicago tax for which you are registered. FOR ITIONL INFORMTION LL IRIS (4747) (TTY ) NOTE: YOU MUST OMPLETE LL INFORMTION ON THIS PGE FOR THIS RETURN TO E ONSIERE OMPLETE. Page

7 hicago epartment of Revenue nnualization Schedule OUNT NUMER TX OE EGINNING PERIO ENING PERIO Note: Please fill out this form if you meet at least one of the following criteria. 1. You paid or remitted at least $2 million dollars for any given tax type for the preceding annual tax year. 2. Your actual liability for this nnual Return Tax during any three consecutive calendar months of the twelve month period immediately preceding the current nnual Tax Year was greater than 50 percent of your liability for such nnual Return Tax for such entire twelve month period. 3. You are a new business that began after July 1st of the current tax year (an incomplete tax year). 4. You voluntarily elect to pay on an actual basis. 5. You did not remit one or more payment coupons or did not file a return in the twelve-month period immediately preceding the tax year now being filed. Tax omputed ue NOTE: O NOT ENTER GROSS HRGE/REEIPT MOUNTS. (efore any applicable commission) 1. July ugust September October November ecember January February March pril May June... Total Tax omputed ue efore ny pplicable ommission. This amount must equal the tax due before commission reported on the tax return. ny difference will be applied to the earliest payment period. Page 1 V