Form Reg-3-C - Business Information Update - 2012 Page 2
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1
2Step 8: Change your owner or officer information
25 Individuals - Social Security Numbers (SSN) required
c
a
___________________________________
_________________
___________________________________
_________________
Name
Title
Name
Title
______________________________________________________
______________________________________________________
Home address - No PO Box number
City
State
ZIP
Home address - No PO Box number
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
____ / ____ / ________
(______) ______ - ________
Date of birth
Telephone
Date of birth
Telephone
_______ - _____ - _________
______
_______ - _____ - _________
______
Ownership percentage:
Ownership percentage:
SSN
SSN
d
b
___________________________________
_________________
___________________________________
_________________
Name
Title
Name
Title
______________________________________________________
______________________________________________________
Home address - No PO Box number
City
State
ZIP
Home address - No PO Box number
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
____ / ____ / ________
(______) ______ - ________
Date of birth
Telephone
Date of birth
Telephone
_______ - _____ - _________
______
_______ - _____ - _________
______
Ownership percentage:
Ownership percentage:
SSN
SSN
26 Businesses - Federal Employers Identification Numbers (FEIN) required
a
c
___________________________________ ____-_____________
___________________________________ ____-_____________
Name
FEIN
Name
FEIN
______________________________________________________
______________________________________________________
Legal address
Legal address
______________________________________________________
______________________________________________________
City
State
ZIP
City
State
ZIP
(______) ______ - ________
______
(______) ______ - ________
______
Ownership percentage:
Ownership percentage:
Phone
Phone
b
d
___________________________________ ____-_____________
___________________________________ ____-_____________
Name
FEIN
Name
FEIN
______________________________________________________
______________________________________________________
Legal address
Legal address
______________________________________________________
______________________________________________________
City
State
ZIP
City
State
ZIP
(______) ______ - ________
______
(______) ______ - ________
______
Ownership percentage:
Ownership percentage:
Phone
Phone
Step 9: Identify a contact person regarding your business
27 Name: __________________________________________
Title: _____________________________________________
28 (______) ______ - _______________
(______) ______ - ________
_________________________
Telephone
Fax
Email address
Step 10: Comments
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Step 11: Sign below
Under penalties of perjury, I state that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Signature: _________________________________________
Title: ______________________
Date:___/___/______
____________________________________________
(_____)_____ - __________
Printed name
Telephone
This form is authorized by 20 ILCS 687/6-1 et seq.; 35 ILCS 5/1et seq.,105/1et seq., 110/1et seq., 115/1et seq., 120/1et seq., 130/1et seq.,
135/1 et seq., 143/10-1et seq., 155/1 et seq., 505/1et seq., 510/1et seq., 615/1et seq., 620/1 et seq., 625/1et seq., 630/1et seq., 635/1et
seq.; 636/5-1 et seq.; 640/2-1 et seq.; 230 ILCS 20/1 et seq.; 25/1et seq., 30/1et seq.; 235 ILCS 5/1-1 et seq.; 305 ILCS 20/5 et seq.,
415 ILCS 5/55.8; 415 ILCS 125/301et seq.; Disclosure of this information may be REQUIRED. Failure to provide information could result in
this form not being processed and possible penalties.
REG-3-C back (R-10/12)
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