Tax / Fee Application - Accounts Receivable Office Page 2

I declare that I have examined this registration form, and to the best of my knowledge and belief,

the information entered on this form is true, correct and complete.

_________________________________________________

_________________________

Signature of owner or officer empowed to sign for corporate entity

Date

_________________________________________________________________________

Print or type name signed above

For Corporations:

_________________________________________________

_________________________

Signature of Secretary

Date

(Affix seal here)

When completed, mail this form to:

City of Peoria

Accounts Receivable Office

419 Fulton Street, Room 111

Peoria, IL 61602

For taxpayer assistance, please call:

(309) 494-8588

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Parent category: Financial