Form Reg-5 Gaming Event Participants List - Illinois Department Of Revenue (Page 2 of 2) in pdf

Step 2: Identify each of your gaming event's workers and sellers

(cont.)

_____________________________________________

__ __ __—__ __—__ __ __ __

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

_____________________________________________

__ __ __—__ __—__ __ __ __

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

Step 3: Sign below

Under penalties of perjury, I swear that I have examined this information and, to the best of my knowledge, it is true,

correct, and complete. I further swear I have read the applicable rulebook and the persons listed as participating are

actual members, volunteers or employees and, for charitable games only - these persons have not participated in more

than 4 events in a calendar year. I further swear these persons listed will receive no compensation from any source.

If you need to identify more, attach additional sheets with the required information in a similar format.

President's signature:_____________________________________________

Date:____/____/________

Secretary's signature:_____________________________________________

Date:____/____/________

REG-5 R-6-04)

IL-492-2091

Form Reg-5 Gaming Event Participants List - Illinois Department Of Revenue Page 2

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