Form Reg-4-C - Financial Institution Irrevocable Letter Of Credit Bond Liquor Gallonage Tax
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1
2Illinois Department of Revenue
REG-4-C
Financial Institution Irrevocable Letter of Credit Bond
Liquor Gallonage Tax
Part 1: Financial institution letter of credit bond type and number
Liquor Gallonage Tax
a
Bond type:
b
Provide the fi nancial institution irrevocable letter of credit number:
2
c
Bond amount: Estimate your average monthly liquor tax liability: $____________ X
= $______________
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
Part 2: Taxpayer and fi nancial institution information
Taxpayer
Financial institution
____________________________________________________
____________________________________________________
Name
Name
____________________________________________________
____________________________________________________
Street address
Street address
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
Part 3: Effective and maturity date of bond
Effective date: __ __/__ __/__ __ __ __
Maturity date: __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Part 4: Bond conditions
If the taxpayer identifi ed in Part 2 fails to pay the Illinois Department of Revenue (IDOR) all moneys, including penalties and
interest, due under the Liquor Control Act (Liquor Gallonage Tax), IDOR is authorized to draw drafts on demand against this
irrevocable letter of credit. The sum of the drafts drawn against this irrevocable letter of credit cannot exceed the bond
amount above, in Part 1, and drafts drawn against it are payable on demand. This letter of credit is issued for a period
of one year and will be renewed automatically for successive one year periods unless IDOR receives a written notice of
cancellation 30 days prior to the maturity date.
Part 5: Financial institution offi cer information
The undersigned offi cer of the fi nancial institution identifi ed in Part 2 is duly authorized by the Board of Directors to execute this
irrevocable letter of credit; and in accordance with the terms of this irrevocable letter of credit, this fi nancial institution will honor
all drafts on demand. The name of the authorized fi nancial institution offi cer, title, and his or her signature are required.
Name:____________________________________________
Title: _____________________________________________
Signature:_________________________________________
Part 6: Financial institution seal
The offi cial seal of the fi nancial institution must be affi xed below.
For offi cial use only
Date approved:
___ ___ / ___ ___ / ___ ___ ___ ___
____________________________________________________
IDOR Director's signature
Month
Day
Year
License number:
________________________________
*146001110*
This form is authorized by the Liquor Control Act of 1934. Disclosure of this information
is REQUIRED. Failure to provide information could result in denial of this application.
REG-4-C (R-12/11)
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