Step 3: Tell us about your owners, general partners, and executive officers
15
List the following information for all owners, general partners, and executive officers. Attach additional sheets if necessary. Do not use
initials for first names. For each individual listed, write a Social Security number. For other entities, write a FEIN.
a
_________________________________________________
__________________________
__________________________
Name (last, first, middle)
SSN or FEIN
Title
_____________________________________________________________________________
(_____)___________________
Number and street, city, state, ZIP
Telephone number
b
_________________________________________________
__________________________
__________________________
Name (last, first, middle)
SSN or FEIN
Title
_____________________________________________________________________________
(_____)___________________
Number and street, city, state, ZIP
Telephone number
c
_________________________________________________
__________________________
__________________________
Name (last, first, middle)
SSN or FEIN
Title
_____________________________________________________________________________
(_____)___________________
Number and street, city, state, ZIP
Telephone number
d
_________________________________________________
__________________________
__________________________
Name (last, first, middle)
SSN or FEIN
Title
_____________________________________________________________________________
(_____)___________________
Number and street, city, state, ZIP
Telephone number
e
_________________________________________________
__________________________
__________________________
Name (last, first, middle)
SSN or FEIN
Title
_____________________________________________________________________________
(_____)___________________
Number and street, city, state, ZIP
Telephone number
f
_________________________________________________
__________________________
__________________________
Name (last, first, middle)
SSN or FEIN
Title
_____________________________________________________________________________
(_____)___________________
Number and street, city, state, ZIP
Telephone number
Step 4: Sign below
Under penalties of perjury, I state that I have examined this application and, to the best of my knowledge, it is true, correct, and complete.
_______________________________________________________
______________________________________________________
Signature of owner, partner, or officer
Date
Typed or printed name of person signing to the left
Mail your completed application to:
REGISTRATION AND RETURNS PROCESSING
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19039
SPRINGFIELD IL 62794-9039
If you have any questions, call our Springfield office weekdays
between 8:00 a.m. and 4:30 p.m. at 217 524-6693 or 217 785-6602.
RT-3 back (R-9/97)
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