Schedule Reg-1-D - Electricity Tax Self-Assessing Purchaser

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Illinois Department of Revenue
Schedule REG-1-D
Electricity Tax Self-Assessing Purchaser
Read this information first -
First time registrants - Attach this schedule to Form REG-1.
Complete Schedule REG-1-D if you wish to purchase electricity for nonresidential use and you elect to pay the Electricity Excise Tax directly
to the Illinois Department of Revenue. You may not self-assess tax on electricity delivered by a municipal system or electric cooperative. Your
election will remain in effect for two years.
Step 1: Identify your business
Business name: ______________________________________________
FEIN:
______
- ______________________
Contact for this schedule:
______________________________________
SSN: _________ - ______ - ____________
(Proprietorship only)
Phone: (_________) _________ - ________________
Step 2: Identify your delivering suppliers of electricity -
To identify more suppliers, attach a sheet using a similar format.
a
d
Supplier’s name:
___________________________________
Supplier’s name: ___________________________________
Address: _________________________________________
Address: _________________________________________
_________________________________________________
_________________________________________________
City
State
ZIP
City
State
ZIP
Your account numbers with this supplier:
Your account numbers with this supplier:
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
b
e
Supplier’s name:
___________________________________
Supplier’s name: ___________________________________
Address: _________________________________________
Address: _________________________________________
_________________________________________________
_________________________________________________
City
State
ZIP
City
State
ZIP
Your account numbers with this supplier:
Your account numbers with this supplier:
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
c
f
Supplier’s name:
___________________________________
Supplier’s name: ___________________________________
Address: _________________________________________
Address: _________________________________________
_________________________________________________
_________________________________________________
City
State
ZIP
City
State
ZIP
Your account numbers with this supplier:
Your account numbers with this supplier:
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Step 3: Pay your fee
$200
Self-assessing purchasers must pay a $200 licensing fee every two years.
___________
Make your check payable to “
Illinois Department of Revenue.”
Step 4: Sign below
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:
__________________________________________
Title: ___________________________
Date: ___ / ___ / ______
Printed name:
_______________________________________
Phone: (_____) ______ - ___________
Mail your completed schedule, with any
CENTRAL REGISTRATION DIVISION 3-222
I LLINOIS DEPARTMENT OF REVENUE
required attachments and payments to:
P O BOX 19039
S PRINGFIELD IL 62794-9039
Schedule REG-1-D (R-07/13)
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