Form Rt-3 - Telecommunications Excise Tax And Infrastructure Maintenance Fees Application For Registration

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Illinois Department of Revenue

RT-3

Telecommunications Excise Tax and Infrastructure

Maintenance Fees Application for Registration

Step 1: Identify your business

Do not write above this line.

IBT no. ___ ___ ___ ___ - ___ ___ ___ ___

Mailing address (if different than Line 6.)

Illinois business tax number

___________________________________________________

Attention

FEIN

___ ___ - ___ ___ ___ ___ ___ ___ ___

Federal employer identification number

___________________________________________________

Post office box or number and street

Certificate of registration numbers, if known.

___ -___ ___ ___ ___

___ ___ -___ ___ ___ ___

___________________________________________________

City

State

ZIP

Business name ______________________________________

(_____)______________________

Telephone number

Corporate name ______________________________________

(_____)______________________

If different than Line 4.

Fax number

Principal business address

When did you begin doing business in Illinois?

___________________________________________________

__ __/__ __/__ __ __ __

Number and street

Month

Day

Year

___________________________________________________

City

State

ZIP

___________________________

County

Step 2: Tell us about your business

Check your type of business ownership.

Did you buy this business from someone?

___ yes

___ no

___ individual (sole proprietor)

If “yes,” complete the following information about the former owner.

___ husband/wife (sole proprietors)

___________________________________________________

Name

___ partnership (number of partners ____)

___ small business corporation

___________________________________________________

Number and street

___ limited liability corporation

___ corporation

___________________________________________________

City

State

ZIP

___ government

(_____)______________________

Telephone number

If you are a corporation, what is your corporation number (issued

by the Illinois Secretary of State) and on what date and in what

___ ___ ___ ___ - ___ ___ ___ ___

IBT number

state were you incorporated?

___________________________

___ ___ - ___ ___ ___ ___ ___ ___ ___

Corporation number

FEIN

___ ___/___ ___/___ ___ ___ ___

___________________

Date of incorporation (month, day, year)

State of incorporation

Do you elect to pay the Optional Telecommunications Infrastructure

Maintenance Fee (TIMF) on gross receipts from municipalities

Will you sell telecommunications services to Illinois customers

to whom you are not required to pay any compensation under an

at retail?

___ yes

___ no

existing franchise agreement and that do not impose a municipal

for resale?

___ yes

___ no

TIMF?

___ yes

___ no

Check all of the types of telecommunications services you

provide.

Continue completing Steps 3 and 4 on the

___ local service

___ long distance

back.

___ paging

___ pay telephone

___ wireless services

___ other __________________________________________

You must specify.

This form is authorized by the Telecommunications Excise Tax Act and the Telecommunications Municipal Infrastructure Maintenance Fee Act. Disclosure of this

RT-3 front (R-9/97)

information is REQUIRED. Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-2287