Schedule Reg-1-O - Owner And Officer Information

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Illinois Department of Revenue
Schedule REG-1-O
Owner and Officer Information
Mail your completed Schedule REG-1-O to:
Central Registration Division, Illinois Department of Revenue, PO Box 19476, Springfield, IL 62794-9476
Read this information first -
First time registrants - 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
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: ______ - __________________
SSN:
_________ - ______ - ____________
(Proprietorship only)
Contact information for person completing this schedule:
Name: _________________________________________________
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
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
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
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
*245401110*
Print
Reset
Schedule REG-1-O (R-07/12)

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