Reg-5-S - Request For Signatures - Gaming Events Form
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1Illinois Department of Revenue
REG-5-S
Request for Signatures - Gaming Events
Read this information first
If you are renewing your gaming event license(s) or you failed to provide a signature with your application, complete
the information listed below. Form REG-5-S must be signed by an owner, officer, partner, executor/trustee. For gaming
event operators, the president, secretary, operator, and person-in-charge is required to sign. Complete Part 3 if you are
responsible for filing returns and paying taxes and fees. Signature stamps are not acceptable.
Part 1: Signature statement
Under penalties of perjury, I swear that I have examined all of the information provided for our organization's registra-
tion or renewal application, and, to the best of my knowledge, it is true, correct, and complete. I attest to the not-for
profit status of our organization.
______________________________________________
_____-____-_________
___/___/_____
Owner's signature
Social Security no.
Date
______________________________________________
_____-____-_________
___/___/_____
President's signature
Social Security no.
Date
______________________________________________
_____-____-_________
___/___/_____
Secretary's signature
Social Security no.
Date
______________________________________________
_____-____-_________
___/___/_____
Person-in-charge's signature
Social Security no.
Date
______________________________________________
_____-____-_________
___/___/_____
Operator's signature
Social Security no.
Date
Part 2: Contact person(s)
Please provide contact information if we have questions regarding your application.
Name:___________________________________________________
Telephone: (____)____-__________
Name:___________________________________________________
Telephone: (____)____-__________
Name:___________________________________________________
Telephone: (____)____-__________
Part 3: Person(s) responsible for filing returns and paying taxes and fees
Please provide the information below about the person who is personally responsible for filing returns and paying taxes
and fees due. If you need to identify more, please attach additional sheets using a similar format.
Name:___________________________________________________
Social Security no.: _______ - ______ - ___________
Address:_________________________________________________
Telephone: (____)____-__________
________________________________________________
Tax type(s):________________________________________
Under penalties of perjury, I state that I am personally responsible for filing and paying the taxes and fees listed above
for the business/organization indicated in this notice.
______________________________________________
____/____/______
Signature
Date
Name:___________________________________________________
Social Security no.: _______ - ______ - ___________
Address:_________________________________________________
Telephone: (____)____-__________
________________________________________________
Tax type(s):________________________________________
Under penalties of perjury, I state that I am personally responsible for filing and paying the taxes and fees listed above
for the business/organization indicated in this notice.
______________________________________________
____/____/______
Signature
Date
REG-5-S (N-2/04)
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