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Responsible Party Information Schedule REG-1-R - Illinois

Responsible Party Information Form. This is a Illinois form and can be used in Department Of Revenue Secretary Of State .
 Fillable pdf Last Modified 1/29/2014
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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: ______________________________________________ If your business is a corporation, are you publicly traded? ___ Yes ___ No If "Yes", provide the ticker symbol: ________________ Contact for this schedule: _______________________________________ Phone: (______) ______ - _________ FEIN: SSN: ______ - __________________ _________ - ______ - ____________ (Proprietorship only) Step 2: Identify the person(s) responsible for filing your business' returns and paying all tax due Printed legal name: ___________________________________________ Legal address: _______________________________________________ Check all for which you are responsible: SSN: _________ - ______ - ____________ Phone: (_____) ______ - ___________ Sales and use taxes and fees Motor vehicle renting tax Withholding income tax Motor fuel and related taxes All taxes and fees Excise taxes and fees - Identify tax/fee: ______________________________ 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: ___________________________________________ Legal address: _______________________________________________ Check all for which you are responsible: SSN: _________ - ______ - ____________ Phone: (_____) ______ - ___________ Sales and use taxes and fees Motor vehicle renting tax Withholding income tax Motor fuel and related taxes All taxes and fees Excise taxes and fees - Identify tax/fee: ______________________________ 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: ___________________________________________ Legal address: _______________________________________________ Check all for which you are responsible: SSN: _________ - ______ - ____________ Phone: (_____) ______ - ___________ Sales and use taxes and fees Motor vehicle renting tax Withholding income tax Motor fuel and related taxes All taxes and fees Excise taxes and fees - Identify tax/fee: ______________________________ 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 any required attachments to: CENTRAL REGISTRATION DIVISION 3-222 ILLINOIS DEPARTMENT OF REVENUE 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) American LegalNet, Inc. www.FormsWorkFlow.com
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