Schedule G For First-Year Irp Applicants Or Business Operational Changes Form - Illinois Secretary Of State

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Secretary of State
Secretary of State.
“Schedule G” for First-Year IRP pplicants or
Business Operational Changes
Secretary of State
Distance records on which this application is
Vehicle Services Department
based must be retained for a period of three years
Commercial & Farm Truck Division
after the expiration of each registration year
501 S. Second St., Rm. 300
(total of five years and nine months). Retention
Springfield, IL 62756
of records is very important to avoid excessive
217-782-4815
penalties that may arise during audit examination.
Name: _________________________________________________________ FEIN : ___________________________
Address: _______________________________________ City/State/Zip : _____________________________________
Telephone #: ____________________________________ Additional Telephone # : _____________________________
Prior to the issuance of your registration, the Office of the Secretary of State, pursuant to 625 ILCS, Sections 5/2-
110 and 5/3-405, requires the following questions to be completed in full. For any question requiring additional
information, additional sheets may be attached. Information provided may require further verification. The Office
of the Secretary of State reserves the right to request documentation for substantiation. For current IRP firms,
please only complete questions regarding the part of your operations that has changed from the previous filing.
Part I, Vehicle Registration Information
1. Indicate how these vehicles were registered previously (includes those under your ownership and leased to another
company). If an existing registrant making changes in business operations, select A. If newly purchased, skip to E;
attach separate sheet if needed. If vehicles were not registered, explain in F.
Existing IRP Registrant – Business Operations Change Only - Firm Number ________________________
A.
Illinois base plate - Name and Plate # ________________________________________________________
B.
Illinois IRP plate - Name and Plate # __________________________________________________________
C.
Foreign plate - (out of state) - State of Issuance__________________________________________________
D.
__________Foreign base plate - Name and Plate #____________________________________________________
________Foreign IRP plate - Name and Plate # ____________________________________________________
New Purchase - (vehicles recently purchased or not in your possession in the previous registration year.)
E.
Purchased from:______________________________________________________________________
Relationship to applicant (if any):_________________________________________________________
Other - Explain in detail. ____________________________________________________________________
F.
________________________________________________________________________________________
________________________________________________________________________________________
2. Have you ever had IRP registration in Illinois or any other jurisdiction? ……………………………………..
YES
NO
If yes, please indicate the Name, Jurisdiction and Firm/Account #: _________________________________________
3. Have you been associated with any company or individual during the past three years that was apportioned in Illinois
or any other jurisdiction? ..........................................................................................................................
YES
NO
If yes, Name and Jurisdiction ______________________________________________________________________
4. Have you ever been denied registration? ..................................................................................................
YES
NO
If yes, explain: __________________________________________________________________________________
5. Have you ever had your registration suspended or revoked? ..................................................................
YES
NO
If yes, explain:___________________________________________________________________________________
Printed by Authority of the State of Illinois. October 2014 — 1M – CFT 23.12

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