Form Reg-4-B - Financial Responsibility Bond Liquor Gallonage Tax
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1
2Illinois Department of Revenue
REG-4-B
Financial Responsibility Bond Liquor Gallonage Tax
Part 1: Financial responsibility bond type and number
a
Bond type: Liquor Gallonage Tax
b
Financial responsibility bond number:
_______________
________
Part 2: Bond amount
2
Estimate your average monthly liquor tax liability. $________________
X
=
$__________________
This is your bond amount. Write this amount as your penal sum in Part 3.
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
Part 3: Financial responsibility bond conditions
We,
____________________________________________________________________________________
(as principal)
Taxpayer's name and address
and
____________________________________________________________________________________
(as surety)
Name and address of surety
are bound to the people of the State of Illinois in the penal sum of $_________________. We hereby bind ourselves, our heirs,
executors, administrators, successors, and assigns to the payment of this amount.
The condition of this bond is that if the principal (taxpayer) identifi ed above, who has applied for a license for Liquor Gallonage Tax,
pays to the Illinois Department of Revenue (IDOR) all amounts becoming due from the principal (taxpayer) under the Liquor Control
Act, then the bond will become void; otherwise, the bond will remain in full force.
The surety identifi ed above may conditionally cancel this bond at any time by fi ling a written notice with IDOR by registered or certifi ed
mail within 90 days. However the surety is not discharged from any liability previously accrued under this bond or that may accrue
before the 90 days expire.
Part 4: Financial responsibility bond signatures and seal requirements
We have signed and sealed this bond on __ __/__ __/__ __ __ __, to be effective __ __/__ __/__ __ __ __.
Month
Day
Year
Month
Day
Year
You must attach a power of attorney.
(Principal's seal)
(Surety's seal)
____________________________________________________
____________________________________________________
Principal's (taxpayer) signature
Surety's signature
____________________________________________________
____________________________________________________
Attorney-in-fact's signature
____________________________________________________
Countersigned by
President's or co-partner's signature
____________________________________________________
____________________________________________________
Corporate secretary's signature (if applicable)
Agent for surety
____________________________________________________
Number and street
____________________________________________________
City
State
ZIP
For offi cial use only
Date approved:
___ ___ / ___ ___ / ___ ___ ___ ___
____________________________________________________
IDOR Director's signature
Month
Day
Year
License number:
________________________________
*145901110*
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-B (R-12/11)
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