Schedule Reg-1-Mr - Illinois Cigarette Manufacturer'S Representative Attach To Form Reg-1 And Reg-1-C

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Illinois Department of Revenue
Schedule REG-1-MR
Illinois Cigarette Manufacturer’s Representative
Attach to Form REG-1 and REG-1-C.
You must file this schedule if you are a cigarette manufacturer and have any “cigarette manufacturer’s representatives”, which are
directors, officers, or employees marketing Illinois stamped cigarette packages to retailers. These products must be obtained from
an Illinois licensed cigarette distributor. A manufacturer’s representative may not possess more than 500 Illinois stamped cigarette
packages at one time and is limited to selling 600 Illinois stamped cigarette packages in a calendar year.
Step 1: Identify your business or organization and the operation’s physical location
Business name: ___________________________________________
FEIN: ______ - __________________
Business address: _________________________________________
SSN: _________ - ______ - ____________
Number and street
(Proprietorship only)
________________________________________________________
Contact for this schedule:________________________________
City
State
ZIP
Email address: ___________________________________________
Phone: (______)______ - _________
Step 2: Identify your representatives:
If you need to identify more representatives, attach a separate sheet(s) using the same format.
Tell us how many representatives you will have in Illinois: _______
d
a
____________________________________
_________________
____________________________________
_________________
Name
Title
Name
Title
____)_____ - ________
_______________________________ (
____)_____ - ________
_______________________________ (
Home street address - No PO Box number
Phone
Home street address - No PO Box number
Phone
_______________________________________________________
_______________________________________________________
City
State
ZIP
City
State
ZIP
_______________________________
________________
_______________________________
________________
Make and model of vehicle
License plate - State & no.
Make and model of vehicle
License plate - State & no.
e
b
____________________________________
_________________
____________________________________
_________________
Name
Title
Name
Title
____)_____ - ________
_______________________________ (
____)_____ - ________
_______________________________ (
Home street address - No PO Box number
Phone
Home street address - No PO Box number
Phone
_______________________________________________________
_______________________________________________________
City
State
ZIP
City
State
ZIP
_______________________________
________________
_______________________________
________________
Make and model of vehicle
License plate - State & no.
Make and model of vehicle
License plate - State & no.
c
____________________________________
_________________
f
____________________________________
_________________
Name
Title
Name
Title
____)_____ - ________
_______________________________ (
____)_____ - ________
_______________________________ (
Home street address - No PO Box number
Phone
Home street address - No PO Box number
Phone
_______________________________________________________
_______________________________________________________
City
State
ZIP
City
State
ZIP
_______________________________
________________
_______________________________
________________
Make and model of vehicle
License plate - State & no.
Make and model of vehicle
License plate - State & no.
Mail your completed form and any required
CENTRAL REGISTRATION DIVISION
3-222
ILLINOIS DEPARTMENT OF REVENUE
attachments to:
PO BOX 19039
SPRINGFIELD IL 62794-9039
Print
Reset
Schedule REG-1-MR (R-07/12)

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