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Illinois Department of Revenue

ST-14 Chicago Soft Drink Tax Return
                                                                                                                                                             Rev 3  Form 077
Account ID: ______________________  This form is for: __________________________________                                                                     E  S ____/____/____
                                                                Reporting Period (month day year - month day year)
                                                                                                                                                             NS   DP    CA   RC
          
 Owner’s name:   _________________________________________________________________________                                                                   Do not write above this line.
Business name:    _________________________________________________________________________
Mailing address:   _________________________________________________________________________
                _________________________________________________________________________

You must round your figures to whole dollars. See instructions. 
Step 1: Figure your taxable receipts
 1    Total receipts - Enter the total you received from sales of soft drinks, including soft drink tax you collected.
     Do not include any other tax you collected.                                                                                                         1   __________________

 2   Deductions
        a  Enter taxes included in Line 1.                               2a __________________

     b     Enter tax-exempt sales included in Line 1.                    2b __________________

        Add Line 2a and Line 2b.                                                                                                                        2    __________________

      3 Taxable receipts (Subtract Line 2 from Line 1.)                                                                                                 3   __________________

Step 2: Figure your net tax and discount
 4    Tax due on receipts. (Multiply Line 3 by 3% (.03).)                                                                                               4   __________________

 5    If you filed and paid by the due date, multiply Line 4 x 1.75% (0.0175).                                                                          5    __________________

 6   Net tax due (Subtract Line 5 from Line 4.)                                                                                                          6   __________________

 7    Excess Chicago Soft Drink tax collected                                                                                                           7    __________________

 8   Total tax (Add Line 6 and Line 7.)                                                                                                                 8     __________________

Step 3: Figure your payment due
 9    Credit amount                                                                                                                                     9   __________________

10   Payment due (Subtract Line 9 from Line 8.) 
     Make your payment to Chicago Soft Drink Tax.                                                                                                       10   __________________

Step 4: Sign below 
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.

________________________________________________________________________________________________
Taxpayer’s signature                                                     Phone                                                                          Date

________________________________________________________________________________________________
Preparer’s signature                                                     Phone                                                                          Date

Mail your completed return and payment to:     Chicago Soft Drink Tax Administration, Illinois Department of Revenue, PO Box 19034, 
                                               Springfield, IL 62794-9034
 This form is authorized by the ordinance of the city council of Chicago and related tax acts imposing the tax for which this form is filed. Disclosure 
 of this information is REQUIRED. Failure to provide this information may result in this form not being processed and may result in a penalty. 

                                                                                                                                                            *707731110*
ST-14 (R-05/17)
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