Form Reg-1 - Illinois Business Registration Application Page 4
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4Step 7: Identify your officers and owners
1
If your business is a corporation, subchapter S corporation, or nonprofit organization, print the legal name and SSN of each officer.
___________________________________________________________________________
_________________
President
Legal name (Last, first, middle initial)
SSN
___________________________________________________________________________
_________________
Vice-President
Legal name (Last, first, middle initial)
SSN
___________________________________________________________________________
_________________
Secretary
Legal name (Last, first, middle initial)
SSN
___________________________________________________________________________
_________________
Treasurer/Comptroller
Legal name (Last, first, middle initial)
SSN
❍
❍
2
Is your business a limited liability company?
yes
no
If yes, attach a list designating each manager and member by name and SSN or FEIN.
3
If your corporation is owned (over 50 percent) by another business, print the legal name and FEIN of the owning entity.
___________________________________________________________________________
___________________
Owning entity name
FEIN
4
If your business is a sole proprietorship, trust/estate, or partnership, provide the legal name and SSN or FEIN of each owner, trustee/
executor, or general partner. Note: If you need to identify more, attach additional sheets with the required information in a similar format.
___________________________________________________________________________
_________________
Legal name (Last, first, middle initial)
SSN
___________________________________________________________________________
_________________
Legal name (Last, first, middle initial)
SSN
___________________________________________________________________________
___________________
Business name of your owner
FEIN
Step 8: Tell us your mailing address
Complete this information only if you want your tax forms and correspondence mailed to an address other than the one listed in Step 3.
Note: All notices and bills (containing confidential tax information), refunds, certificates, and tax forms will be sent to this address.
______________________________________________
_______________________________________________
In-care-of name. Please print.
Street address
_________________________________________________________________________________________________
City
State
ZIP
Step 9: Sign below
1
Person responsible for filing returns and paying taxes:
If in Step 4, “Withholding,” “Sales,” “Use,” “Service,” “Motor vehicle
renting,” or “Hotel/motel” was checked, the person(s) that will be personally responsible for filing returns and paying the tax due must
complete the following information. This signature is required in addition to the signature in Item 2 of this step. The same person can
sign both statements. Note: If you need to identify more, attach sheets with the required information in a similar format.
Check tax responsibility(ies):
Withholding
Sales, Use, or Services
Motor vehicle renting
Hotel/motel
_________________
______________________________________
___/___/______
_________________________________________
Signature
Month Day
Year
Printed name (Last, first, middle initial)
SSN
_________________________________________________________________________________________________
Street address
City
State
ZIP
Check tax responsibility(ies):
Withholding
Sales, Use, or Services
Motor vehicle renting
Hotel/motel
_________________
______________________________________
___/___/______
_________________________________________
Signature
Month Day
Year
Printed name (Last, first, middle initial)
SSN
_________________________________________________________________________________________________
Street address
City
State
ZIP
2
This must be completed by the person completing this application and verifying the information. Signature stamps are not acceptable.
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
Month Day
Year
Printed name (Last, first, middle initial)
Step 10: Mail your application
If you attached additional sheets for any step in this application, please check here.
If you have any questions or need help completing your application, please call us weekdays between 8 a.m. and 5 p.m.
Email:
Phone:
Mail:
CENTRAL REGISTRATION DIVISION
centreg@revenue.state.il.us
217 785-3707
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19476
SPRINGFIELD IL 62794-9476
This form is authorized by 20 ILCS 687/6 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., 415/1 et 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.; 640/2-1 et seq.; 230 ILCS 25/1et seq., 30/1et seq., 20/1 et seq.; 235 ILCS 5/1-1 et seq.; 305 ILCS 20/5 et seq., 687/6-1 et seq.; 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. This form has been approved by the Forms Management Center. IL-492-0001
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