Form Reg-8-A - Motor Fuel And Other Fuel Information (Distributor, Supplier, Receiver, Or Blender) Page 4

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27 Identify your company’s financial institution.
___________________________________________________
Name
___________________________________________________
Address (number and street)
___________________________________________________
City
State
ZIP
Sign Below
The person(s) that will be personally responsible for filing returns and paying the tax due must sign below. Acceptance of responsible party
is designated by original signature of a corporate officer, owner or partner. I accept personal responsibility for the filing of returns and the
payment of taxes due.
________________________________________________________________________________________________________________
Responsible party (as listed in Step 3)
Title
Date
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 stamps are not acceptable.
________________________________________________________________________________________________________________
Signature of owner, partner or authorized officer (as listed in Step 3)
Title
Date
Stamp corporate seal below
Mail to:
If your company has no seal, check this box.
MOTOR FUEL TAX AND REFUNDS SECTION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19477
SPRINGFIELD, IL 62794-9477
If you have questions, visit our website at tax.illinois.gov or call
us weekdays between 8:00 a.m. and 4:00 p.m. at 217 782-2291.
Reset
Print
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
information is required. Failure to provide information may result in this form not being processed and may result in a penalty.
Page 4
REG-8-A (R-03/13)

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