Schedule Reg-1-R - Responsible Party Information - 2014
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Illinois Department of Revenue
Schedule REG-1-R
Responsible Party Information
Read this information first -
First time registrants - Attach this schedule to Form REG-1.
Complete this schedule to identify the person(s) who will be responsible for filing returns and paying taxes due. If you need to identify more,
attach a separate sheet using a similar format. You can fax Schedule REG-1-R to us at 217 785-6013.
Step 1: Identify your business or organization
Business name: ______________________________________________
FEIN: ______ - __________________
If your business is a corporation, are you publicly traded? ___ Yes ___ No
SSN:
_________ - ______ - ____________
(Proprietorship only)
If “Yes”, provide the ticker symbol: ________________
Contact for this schedule: _______________________________________
Phone: (______) ______ - _________
Step 2: Identify the person(s) responsible for filing your business’ returns and paying all tax due
Printed legal name: ___________________________________________
SSN: _________ - ______ - ____________
Legal address: _______________________________________________
Phone: (_____) ______ - ___________
Check all for which you are responsible:
Sales and use taxes and fees
Motor fuel and related taxes
All taxes and fees
Motor vehicle renting tax
Excise taxes and fees - Identify tax/fee: ______________________________
Withholding income tax
Other: ________________________________________________________
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. I
further attest that I will be responsible for filing returns and paying the taxes indicated.
Signature: ___________________________________________________
Title: ______________________
Date: ___ / ___ / ______
If you need to identify another person, complete the following:
Printed legal name: ___________________________________________
SSN: _________ - ______ - ____________
Legal address: _______________________________________________
Phone: (_____) ______ - ___________
Check all for which you are responsible:
Sales and use taxes and fees
Motor fuel and related taxes
All taxes and fees
Motor vehicle renting tax
Excise taxes and fees - Identify tax/fee: ______________________________
Withholding income tax
Other: ________________________________________________________
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. I
further attest that I will be responsible for filing returns and paying the taxes indicated.
Signature: ___________________________________________________
Title: ______________________
Date: ___ / ___ / ______
If you need to identify another person, complete the following:
Printed legal name: ___________________________________________
SSN: _________ - ______ - ____________
Legal address: _______________________________________________
Phone: (_____) ______ - ___________
Check all for which you are responsible:
Sales and use taxes and fees
Motor fuel and related taxes
All taxes and fees
Motor vehicle renting tax
Excise taxes and fees - Identify tax/fee: ______________________________
Withholding income tax
Other: ________________________________________________________
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. I
further attest that I will be responsible for filing returns and paying the taxes indicated.
Signature: ___________________________________________________
Title: ______________________
Date: ___ / ___ / ______
Mail your completed schedule, with
CENTRAL REGISTRATION DIVISION 3-222
ILLINOIS DEPARTMENT OF REVENUE
any required attachments to:
PO BOX 19030
SPRINGFIELD IL 62794-9030
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.
Schedule REG-1-R (R-01/14)
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