Schedule Reg-1-O - Owner And Officer Information Form
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Illinois Department of Revenue
Schedule REG-1-O
Owner and Officer Information
Read this information first -
If you are a first time registrant, attach this schedule to Form REG-1.
If your organization is a:
then complete Step 2 to identify:
Proprietorship
— the owner (if husband/wife or civil union, enter both individuals’ information)
Partnership
— each general partner
Corporation or S Corp*
— the president, secretary, and treasurer
*If publicly traded (identify below)
— the chief operating officer and chief financial officer
Trust or estate
— each trustee or executor
Not-for-profit organization
— the president, secretary, or treasurer
Limited liability company
— each manager and member
Governmental unit
— one contact person (for example, the liaison)
Step 1: Identify your business or organization
Business name: _______________________________________________
FEIN: ______ - __________________
If your business is a corporation, are you publicly traded? ___ Yes ___ No
SSN: _________ - ______ - ____________
(Proprietorship only)
If “Yes”, provide the ticker symbol: ________________
Contact for this schedule: _________________________________
Phone: (______) ______ - _________
Step 2: Identify your owners and officers
1 Individuals - For each individual required, complete the following information (including the Social Security number).
a
c
____________________________________
_________________
____________________________________
_________________
Name
Title
Name
Title
________________________________________________________
________________________________________________________
Home address - No PO Box number
Home address - No PO Box number
City
State
ZIP
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
Date of birth
Phone
_______ - _____ - _________
_______
_______ - _____ - _________
_______
Ownership percentage:
Ownership percentage:
Social Security number
Social Security number
b
d
____________________________________
____________________________________
_________________
_________________
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
Phone
Date of birth
Phone
_______ - _____ - _________
_______
_______ - _____ - _________
_______
Ownership percentage:
Ownership percentage:
Social Security number
Social Security number
2 Businesses - For each business that is an owner, complete the following information (including the federal employer identification number (FEIN)).
a
b
____________________________________
____-_____________
____________________________________
____-_____________
Name
FEIN
Name
FEIN
________________________________________________________
________________________________________________________
Legal address
Legal address
________________________________________________________
________________________________________________________
City
State
ZIP
City
State
ZIP
(______) ______ - ________
_______
(______) ______ - ________
_______
Ownership percentage:
Ownership percentage:
Phone
Phone
Step 3: Remove owners and officers (for current registrants only, not new registrants)
Complete the following information (including the Social Security number) if you need to remove an owner or officer from our registration records.
a
b
____________________________________
_________________
____________________________________
_________________
Name
Title
Name
Title
____ / ____ / ________
(______) ______ - ________
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
Date of birth
Phone
_______ - _____ - _________
____ / ____ / ________
_______ - _____ - _________
____ / ____ / ________
Social Security number
Date ceased as owner/officer
Social Security number
Date ceased as owner/officer
Step 4: Sign here
Under penalties of perjury, I certify I have examined all the information provided for my registration or renewal application and, to the best of my
knowledge, it is true, correct, and complete.
Signature:_____________________________________________________
Date: ___/___/_______
Printed name:
_______________________________________________
Title:
___________________________
Fax your completed schedule to 217 785-6013 or mail to:
CENTRAL REGISTRATION DIVISION 3-222
ILLINOIS DEPARTMENT OF REVENUE
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this
PO BOX 19030
information is required. Failure to provide information may result in this form not being processed and may result in a penalty.
SPRINGFIELD IL 62794-9030
Schedule REG-1-O (R-04/16)
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