Form Reg-5 Gaming Event Participants List - Illinois Department Of Revenue

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Illinois Department of Revenue
REG-5
Gaming Event Participants List
Read this information first
We must receive your completed Form REG-5 prior to the date of the event in which the participants you are identifying will be
participating. If you need to add or make changes to this information you must contact us prior to the event by calling us
weekdays between 8:00 a.m. and 4:30 p.m. at 217 524-4164. If you need to identify more than provided for, attach additional
sheets with the required information in a similar format.
Bingo applicants only - You must keep this information in your books and records. Do not send this information to us.
Step 1: Identify your organization
Name:______________________________________________________________________________________
Illinois Business Tax number (IBT no.):__ __ __ __ - __ __ __ __
Date of the gaming event: ___/___/______
Charitable games license number:
___________
Pull Tab license number:___________
Step 2: Identify each of your gaming event's workers and sellers
Y
ou must complete the following information for each participant (i.e., worker, seller) of your gaming event. Do not include those
workers who set up, sell concessions, work in the kitchen, clean up, or provide security for persons or the property. You must
also include any employee of your organization that will sell pull tabs and jar games in addition to his or her regular duties.
Employees can not be hired for the sole purpose of selling pull tabs or jar games.
Note: If any of your participants are members of your organization or members of your auxiliary organization, they must have
been members for at least 30 days prior to the completion of this information.
_____________________________________________
__ __ __—__ __—__ __ __ __
Last name
First name and middle initial
Social Security number
_____________________________________________
__ __/__ __/__ __ __ __
Street address
City
State ZIP
Date of birth
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
_____________________________________________
__ __ __—__ __—__ __ __ __
Last name
First name and middle initial
Social Security number
_____________________________________________
__ __/__ __/__ __ __ __
Street address
City
State ZIP
Date of birth
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
_____________________________________________
__ __ __—__ __—__ __ __ __
Last name
First name and middle initial
Social Security number
_____________________________________________
__ __/__ __/__ __ __ __
Street address
City
State ZIP
Date of birth
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
_____________________________________________
__ __ __—__ __—__ __ __ __
Last name
First name and middle initial
Social Security number
_____________________________________________
__ __/__ __/__ __ __ __
Street address
City
State ZIP
Date of birth
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_____________________________________________
__ __ __—__ __—__ __ __ __
Last name
First name and middle initial
Social Security number
_____________________________________________
__ __/__ __/__ __ __ __
Street address
City
State ZIP
Date of birth
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
_____________________________________________
__ __ __—__ __—__ __ __ __
Last name
First name and middle initial
Social Security number
_____________________________________________
__ __/__ __/__ __ __ __
Street address
City
State ZIP
Date of birth
REG-5 (R-6-04)
IL-492-2091

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