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Application For State Of Illinois Specialty Retailers Liquor License Form. This is a Illinois form and can be use in Liquor Control Commission Statewide.
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Tags: Application For State Of Illinois Specialty Retailers Liquor License, IL 567-0058, Illinois Statewide, Liquor Control Commission
Illinois Liquor Control
Commission
Pat Quinn
Governor
100 W. RANDOLPH ST.
SUITE 7-801
CHICAGO, ILLINOIS 60601
TELEPHONE: 312-814-2206
FAX: 312-814-2241
TDD: 312-814-1844
101 W. JEFFERSON ST.
SUITE 3-525
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217-782-2136
FAX: 217-524-1911
WEB SITE: www.state.il.us/LCC
APPLICATION FOR STATE OF ILLINOIS SPECIALTY RETAILER’S LIQUOR LICENSE
BREW PUB — CATERER RETAILER — WINE MAKER RETAILER
The following are considered specialty retailer’s liquor licenses. Check the box that applies to the type/class of license for which
application is being made. Be sure to obtain and complete all of the supporting documents required for the particular license class.
A.
BREW PUB
FEE:
$1,050.00
A “Brew Pub” means a person who manufactures beer only at a designated premises to make sales to importing distributors, distributors, and to nonlicensees for use and consumption only, who stores beer at the designated premises, and who is allowed to sell at retail from the licensed premises,
provided that a brew pub licensee shall not sell for off-premises consumption more than 50,000 gallons per year. (ILCS 5/1-3-33)
SUPPORTING DOCUMENTS REQUIRED:
• PHOTOCOPY OF LOCAL LIQUOR LICENSE;
• REGISTRATION STATEMENT(S) FORM ENCLOSED;
• COPY OF FORM(S) 5100.31: CERTIFICATION/EXEMPTION OF
LABEL/BOTTLE APPROVAL (DOWNLOAD AT WWW.TTB.GOV);
B.
• TAX BOND ACQUIRED BY ONE OF THE ENCLOSED FORMS BELOW:
a) RL-1 TAX STATEMENT OF LIABILITY;
b) REG-4-D LETTER OF CREDIT BOND; or
c) REG-4-A (LIQUOR GALLONAGE TAX BOND) CERT. OF DEPOSIT;
CATERER RETAILER
FEE:
$200.00
A “Caterer retailer” means a person who serves alcoholic liquors for consumption, either on-site or off-site, whether the location is licensed or unlicensed,
as an incidental part of food service. Prepared meals and alcoholic liquors are sold at a package price agreed upon under contract. ILCS 5/1-34
SUPPORTING DOCUMENTS REQUIRED: PHOTOCOPY OF LOCAL LIQUOR LICENSE
C.
WINE MAKER RETAILER
FEE:
$100.00
A wine-maker’s retail license shall allow the licensee to sell and offer for sale at retail in the premises specified in such license not more than 50,000 gallons of wine
per year for use or consumption, but not for resale in any form; this license shall be issued only to a person licensed as a first-class or second-class wine-maker.
A wine-maker’s retail licensee, upon receiving permission from the Commission, may conduct business at a second location that is separate from the location
specified in its wine-maker’s retail license.
SUPPORTING DOCUMENTS REQUIRED: PHOTOCOPY OF LOCAL LIQUOR LICENSE
D.
WINE MAKER RETAILER (SECOND LOCATION)
One wine-maker’s retail license for a second location may be issued to a wine-maker’s retail
license holder allowing the licensee to sell and offer for sale at retail in the premises specified in
the wine-maker’s retail license-second location up to 50,000 gallons of wine per year for use and
consumption and not for resale that was produced at the licensee’s first location.
FEE:
$350.00
Provide current wine-maker
retailer license number:
CURRENT WINE-MAKER RETAIL LICENSE NO.
SUPPORTING DOCUMENTS REQUIRED: PHOTOCOPY OF LOCAL LIQUOR LICENSE
MAKE CHECK OR MONEY ORDER PAYABLE TO THE ILLINOIS LIQUOR CONTROL COMMISSION. The
Commission does not accept U.S. currency/cash as payment.
IMPORTANT NOTICE: THE ILLINOIS LIQUOR CONTROL COMMISSION IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY UNDER THE ILLINOIS LIQUOR CONTROL ACT (235 ILCS
5/1 ET SEQ.). DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION WILL RESULT IN THE NON-ISSUANCE OF YOUR LICENSE. FORM APPROVED BY THE
STATE FORMS MANAGEMENT CENTER.
IL 567-0058 (01/2007)
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FOR OFFICE
USE ONLY
LICENSE NO.
DATE ISSUED
EXPIRATION DATE
COUNTER
Application for State of Illinois Specialty Retailer’s Liquor License
If you want your renewal application, your license
certificate and other ILCC correspondence sent to
your “corporate” address, please check this box.
1. APPLICANT - CORPORATE INFORMATION
A.
FEIN
Enter your Federal Employer Identification Number (FEIN) in this box. The FEIN is a nine-digit number issued by the U.S. Internal Revenue Service.
This number is used for verification purposes only. If you do not have an FEIN number, call 1-800-829-3676 for general information on how to apply
and to obtain the forms you will need. NOTE, if you have filed an application for your FEIN number, the Commission will accept your application.
FEIN #
B.
ILLINOIS BUSINESS TAX NUMBER (IBT OR SALES TAX NO.)
Enter the eight-digit Illinois Dept. of Revenue Business Tax (Sales Tax) Number. YOU MUST HAVE THIS NUMBER IN ORDER FOR A LICENSE TO BE
ISSUED. If you need to obtain this number, call the Illinois Department of Revenue in Chicago at 312-814-5258 or in Springfield at 217-785-2889.
ILLINOIS BUSINESS TAX #
C. TELEPHONE
Enter the area code/telephone number/extension of the sole proprietorship, corporation, etc.
AREA CODE/TELEPHONE NO.
EXT.
D.
COUNTY
Enter the county where the sole proprietorship, corporation, etc. is located.
COUNTY
E.
NAME
Enter the name of the sole proprietorship (assumed name), partnership, corporation (Illinois, national, or foreign), or limited liability company in this
box. Note! This name must be consistent with the name printed on your local liquor license and on your Illinois Dept. of Revenue
Sales Tax Registration Certificate.
NAME
F.
ADDRESS
Enter the street address, city, state, and Zip Code of the sole proprietorship, corporation, etc..
ADDRESS
IL 567-0058 (01/2007)
CITY
STATE
ZIP CODE
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2. STATUS OF BUSINESS
Check the applicable box (assumed name/sole proprietorship, partnership, Illinois corporation, foreign corporation, limited liability company) which corresponds to your business’ official papers filed with the Office of the Secretary of State.
Based on the box that you check, provide the date of the filing of the sole proprietorship/assumed name with the county clerk; in the case of a co-partnership,
the date of formation of the partnership; in the case of an Illinois corporation, the date of its incorporation; in the case of a foreign corporation, the foreign
state where it was incorporated and the date, as well as the date of its becoming qualified under the “Business Corporation Act of 1983” to transact business
in the State of Illinois; in the case of a limited partnership, the date of formation of such partnership; or in the case of a limited liability company, the date of
formation of such entity.
NOTE! In the case of a sole proprietorship, Section 5/6-2 of the Illinois Liquor Control Act requires that the business owner reside
within the jurisdiction that grants the local liquor license.
A.
B.
C.
D.
E.
ASSUMED NAME
DATE FILED WITH COUNTY CLERK:
PARTNERSHIP
DATE OF FORMATION:
ILLINOIS CORPORATION
DATE OF INCORPORATION:
FOREIGN CORPORATION
LIMITED LIABILITY COMPANY
STATE OF INCORPORATION:
DATE QUALIFIED TO DO BUSINESS IN ILLINOIS:
DATE FORMED:
3. OWNERSHIP INFORMATION
Provide the owner/officer/partner information in accordance with the business status described under Question 2. This information must be submitted for
all owners/officers/partners. The same information must be submitted for shareholders with interests equal to or exceeding 5%.
The following information must be provided by every individual applicant, sole proprietor, partner, corporate officer or director (whether or not they
own any stock), shareholder owning in the aggregate equal to or more than 5% of the stock, (including officers, directors and stockholders of equal
to or more than 5% for all corporate shareholders), and/or manager or agent conducting the business. Indicate the total percentage of stock of the
corporation, if any, which is held by persons who have less than a 5% interest. All Not-for-profit organizations and associations must provide the
requested information for all corporate officers, directors and managers. If additional space is needed, provide information on a separate sheet(s)
in the same format as this application requires. Before completing this section, check Question No. 6 - Eligibility.
For each owner/officer/partner/5% shareholder, provide full name, home address, city, state, Zip Code, social security number, date of birth, sex, title/
position, home telephone number, and percentage ownership. Percentage ownership should equal 100%. If there are a number of shareholders owning
less than 5%, indicate the aggregate total of ownership under E.
A.
SOCIAL SECURITY NO.
B.
DATE OF BIRTH
DATE OF BIRTH
SEX
AREA CODE/TELEPHONE NO.
CITY
TITLE/POSITION
AREA CODE/TELEPHONE NO.
CITY
TITLE/POSITION
AREA CODE/TELEPHONE NO.
HOME ADDRESS
SEX
TITLE/POSITION
HOME ADDRESS
SEX
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
E.
DATE OF BIRTH
CITY
HOME ADDRESS
SEX
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
D.
DATE OF BIRTH
NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NO.
C.
HOME ADDRESS
NAME (LAST, FIRST, MIDDLE INITIAL)
CITY
TITLE/POSITION
AREA CODE/TELEPHONE NO.
TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST
IL 567-0058 (01/2007)
STATE
ZIP
% OWNED
STATE
ZIP
% OWNED
STATE
ZIP
% OWNED
STATE
ZIP
% OWNED
%
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If you want your renewal application, your license
certificate and other ILCC correspondence sent to
your “corporate” address, please check this box.
4. BUSINESS PREMISE INFORMATION
A.
NAME/DOING BUSINESS AS (D/B/A)
Enter the name of the business which will be selling or serving alcoholic beverages at the licensed premises. Note! This name must be consistent
with the name printed on your local liquor license and on your Illinois Department of Revenue Sales Tax Registration Certificate.
NAME (DOING BUSINESS AS D/B/A )
B.
TELEPHONE
Enter the area code/telephone number/extension at the business premise location.
AREA CODE/TELEPHONE NO.
EXT.
C.
ADDRESS
In the next five boxes enter the address, city, state, Zip Code and county of the business premises. This address information must be consistent
with information on your local liquor license and on your Illinois Department of Revenue Sales Tax Certificate.
Remember, you MUST close on the business purchase prior to applying for your state license. Proof of business purchase is
required (ie, bill of sale, closing statement). IMPORTANT: You must also present proof that the applicant (ie, Corporation, LLC,
Partnership, or Sole-Proprietor) has the right to possession of the property (ie, Deed or Lease). If there is an existing state liquor
license on the premise, this license should be surrendered (if available). The applicant will also need to provide the State of
Illinois Liquor Commission with a Bulk Sales Release Order (“Address Release”) if applicable, which can be obtained by contacting the Illinois Dept. of Revenue at 312-814-3063.
ADDRESS
D.
STATE
CITY
ZIP CODE
COUNTY
BUSINESS TYPE
Check the one box which best describes the type of business in operation. If the selections listed are inappropriate, describe the business under “other”.
A.
B.
C.
D.
E.
DRUG STORE/PHARMACY
RESTAURANT
CONVENIENCE
SUPERMARKET
E.
F.
G.
H.
LIQUOR STORE
DEPARTMENT STORE
BAR/TAVERN
HOTEL/MOTEL
I.
J.
K.
L.
CONVENIENCE & GAS
SMALL GROCERY
GAS STATION
OTHER
WAREHOUSING
If any of your inventory is warehoused, provide the name, street address, city, state, Zip Code and county of the warehouse.
ADDRESS
F.
CITY
STATE
ZIP CODE
COUNTY
LEASED PREMISES
If you lease your premises, the lease must cover the full term of the license. If you lease, provide the landlord’s name, telephone number, street address,
city, state, Zip Code and county.
LANDLORD NAME
ADDRESS
IL 567-0058 (01/2007)
AREA CODE/TELEPHONE NO.
CITY
STATE
ZIP CODE
COUNTY
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5. LOCAL LICENSE INFORMATION/LIQUOR LICENSE HISTORY
A.
LOCAL LIQUOR LICENSE INFORMATION
YOU MUST PROVIDE A PHOTOCOPY OF YOUR LOCAL LIQUOR LICENSE
Your local license must contain the expiration date, issue date, and
license number.
Please enter the local liquor license number, the date it was issued, the date it expires, the municipality or county that issued the license and the date
you intend to begin selling alcoholic beverages at this business premise. Alcoholic beverages may not be sold or offered for sale prior to the date
that the State liquor license is issued. If you have begun selling alcoholic beverage products before obtaining this license, you will be required to
fill out a “deliquency affidavit” to explain the circumstances.
Note! In unincorporated areas, the county acts as the local liquor licensing authority.
MUNICIPALITY/COUNTY ISSUING LOCAL LIQUOR LICENSE
B.
LOCAL LICENSE NO. DATE ISSUED
EXPIRATION DATE
DATE YOU BEGAN LIQUOR SALES AT THIS PREMISE
FIRST LICENSE APPLICATION - LICENSE HISTORY
Indicate by checking the correct box whether or not this is the corporation’s, sole proprietorship’s, etc’s first application for a State liquor license at
any premises. If you check “no”, indicate the date of your first State liquor license application. Also indicate whether the license was granted, denied
or withdrawn. Provide the address of your first State liquor license application. If you have ever had a license application denied or if you ever
withdrew an application, please provide a written statement describing the reason and circumstances.
IS THIS YOUR FIRST STATE LICENSE APPLICATION?
YES
NO
IF NO, PROVIDE DATE FIRST APPLIED:
DISPOSITION:
GRANTED
DENIED
WITHDRAWN
ADDRESS OF FIRST STATE APPLICATION:
C.
FEDERAL REGISTRATION AND RETURN
To sell alcoholic beverages, you are required to register with the Federal Alcohol and Tobacco Tax and Trade Bureau (TTB) on a yearly basis.
HAVE YOU FILED TTB FORM 5630.5d “ALCOHOL DEALER REGISTRATION AND RETURN”?
YES
NO
If NO is checked, TTB Form 5630.5d may be obtained from the National Revenue Center at 800-937-8864 or downloaded at www.ttb.gov.
D.
TYPE OF LIQUOR LICENSE
Check the box which describes the manner in which you sell alcoholic beverages to consumers - “on-premise”; “off-premise”; or “combined”. This
information must be consistent with your approval granted by the local liquor licensing authority.
ON-PREMISE CONSUMPTION (PATRONS CONSUME ALCOHOLIC BEVERAGES ON PREMISE ONLY)
OFF-PREMISE CONSUMPTION (CARRY-OUT PURCHASES ONLY)
ON/OFF-PREMISE CONSUMPTION COMBINATION (BOTH ON-PREMISE CONSUMPTION AND CARRY-OUTS)
6. CERTIFICATE OF INSURANCE
ATTACH PHOTOCOPY OF YOUR “CERTIFICATE OF INSURANCE” (NOT THE “POLICY DECLARATION”)
You MUST provide a copy of your Certificate of Insurance if you sell liquor for on-premise or on/off premise consumption. The Certificate of
Insurance must show that you have liquor liability insurance and must include the following: 1) The applicant showed as the insured (e.g. if the
applicant is a corporation, then the corporation’s name must be listed; if the applicant is a sole proprietor, the the sole proprietor’s name must be
listed.); 2) The address of the location where the liquor is being consumed; and 3) The dates of coverage and the coverage limits.
IL 567-0058 (01/2007)
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6. ELIGIBILITY QUESTIONS
These questions apply to the applicant and any other person listed under Question 3. These questions MUST be answered. IF
THE QUESTIONS ARE NOT CHECKED, THE APPLICATION WILL BE REJECTED. If any question is checked “yes”, a written, detailed
explanation is required and must be attached to this application.
6-17
YES
NO
HAVE YOU FAILED OR NEGLECTED TO REGISTER WITH THE FEDERAL TAX & TRADE BUREAU (TTB)? IF SO,
PLEASE CONTACT THE TTB AT 800-937-8864 OR 513-684-2979.
6-18
YES
NO
ARE YOU DELINQUENT IN THE PAYMENT OF ANY ILLINOIS BUSINESS TAXES (SALES, WITHHOLDING, ETC.)?
6-19
YES
NO
ARE YOU DELINQUENT UNDER THE “CASH BEER” LAW?
6-20
YES
NO
ARE YOU DELINQUENT UNDER THE “30-DAY CREDIT” LAW?
6-22
YES
NO
HAVE YOU EVER APPLIED FOR AND BEEN DENIED A LIQUOR LICENSE?
6-23
YES
NO
HAVE YOU HAD ANY PREVIOUS LIQUOR LICENSE REVOKED?
6-24
YES
NO
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
6-25
YES
NO
HAVE YOU EVER BEEN CONVICTED OF A GAMBLING OFFENSE AS DEFINED UNDER SECTION 5/6-2 OF THE
ACT WHICH INCLUDES OFFENSES ENUMERATED IN 720 ILCS 5/28-1(a)1-11, “GAMBLING;” 720 ILCS 5/28-1.1(a)(d) “SYNDICATED GAMBLING;” AND 720 ILCS 5/28-3 “KEEPING A GAMBLING PLACE”?
6-26
YES
NO
DO YOU POSSESS A CURRENT FEDERAL WAGERING STAMP? (ISSUED BY THE UNITED STATES INTERNAL
REVENUE SERVICE TO TAX WAGERING ACTIVITY)
6-27
YES
NO
ARE YOU, OR ANY OTHER PERSON WITH A DIRECT INTEREST IN YOUR PLACE OF BUSINESS, A PUBLIC
OFFICIAL OR LAW ENFORCEMENT OFFICIAL IN THE SAME JURISDICTION AS THE LICENSE?
6-28
YES
NO
HAVE YOU RECEIVED OR BORROWED MONEY OR ANYTHING OF VALUE DIRECTLY OR INDIRECTLY FROM
ANY OTHER LICENSEES, REPRESENTATIVES OF A LICENSEE, OR SUPPLIERS OF ALCOHOLIC PRODUCTS?
6-30
YES
NO
IF OPERATING AS A SOLE PROPRIETORSHIP OR A PARTNERSHIP, ARE YOU OR YOUR PARTNER(S) CURRENTLY NOT CITIZENS OF THE UNITED STATES OR RESIDENT ALIENS WITH LEGAL STATUS?
7. HOURS OF OPERATION
List the daily hours open for business. This information will assist Commission field agents in choosing an inspection time which causes the least disruption
to the business.
MON
TUES
WED
THURS
FRI
SAT
SUN
8. SIGNATURE/TITLE/DATE
Please sign and date the application form and provide your title with the organization. The application must be signed by an owner, an officer, a partner or
an officially authorized agent of the business. The signature must be an original, rubber stamps are not accepted.
I, THE UNDERSIGNED APPLICANT OR AUTHORIZED AGENT THEREOF, SWEAR OR AFFIRM THAT: THE MATTERS STATED IN THE
FOREGOING APPLICATION ARE TRUE AND CORRECT; THEY ARE MADE UPON MY PERSONAL KNOWLEDGE AND INFORMATION; THEY ARE MADE FOR THE PURPOSE OF REQUESTING THE STATE OF ILLINOIS TO ISSUE THE LICENSE HEREIN APPLIED
FOR; THE APPLICANT IS QUALIFIED AND ELIGIBLE TO OBTAIN THE LICENSE APPLIED FOR; AND THE APPLICANT WILL NOT
VIOLATE ANY OF THE LAWS OF THE UNITED STATES OF AMERICA OR THE STATE OF ILLINOIS, IN PARTICULAR, THE ILLINOIS
LIQUOR CONTROL ACT, RULES AND REGULATIONS, AND THE CIVIL RIGHTS SECTIONS THEREOF.
FURTHER, I AGREE TO NOTIFY THIS COMMISSION WITHIN 30 WORKING DAYS OF CHANGES IN ANY OF THE ABOVE INFORMATION.
(NOTE: IF THE PERSON SIGNING THIS APPLICATION IS NOT LISTED IN SECTION 3, THEY MUST PROVIDE THE STATE WITH THEIR
PERSONAL INFORMATION AS INDICATED IN SECTION 3 EVEN IF THEY DO NOT OWN 5% OR MORE OF THE BUSINESS.)
SIGNATURE OF APPLICANT/AUTHORIZED AGENT
IL 567-0058 (01/2007)
TITLE/POSITION
DATE
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Registration Statement
(Illinois Compiled Statutes, Chapter 235)
TO THE ILLINOIS LIQUOR CONTROL COMMISSION
Pursuant to the requirement of Section 5/6-9 of the Illinois Liquor Control Act the undersigned, a
(Insert -- Manufacturer, Distributor, Importing Distributor, or Non-resident Dealer)
does hereby register with said Commission the following named persons or companies as being the only ones to whom the
undersigned has granted the right to sell or distribute at wholesale within the State of Illinois, one or more of those alcoholic
liquors which bear trade-marks, brands or names owned or controlled by the undersigned. The undersigned does hereby further
register opposite the name of said persons or companies, the respective trademarks, brands or names, owned or controlled by
the undersigned, concerning which said persons have been given such distributing rights and the rspective geographical
territories for which such distributing rights have been given to said persons or companies, and the period of time for which such
rights are granted to such person.
NAME, ADDRESS, CITY, STATE AND
ZIP CODE OF WHOLESALER
TRADE-MARK BRAND, OR
NAME OF ITEM
TIME
PERIOD
GEOGRAPHICAL
TERRITORY
CORPORATE NAME:
IMPORTANT NOTICE
This state agency is requesting disclosure of information that is necessary to accomplish the statutory
purpose as outlined under the Illinois Liquor Control
Act, Ch. 235, Ill. Comp. Stat., 5/6-9. Disclosure of this
information is MANDATORY.
Failure to provide any information will result in
nonissuance of your license and/or nonregistration of
your products. This form has been approved by the
Forms Management Center.
ADDRESS:
(City or Town)
SIGNED BY:
(Title)
DATE:
STATE LICENSE #
IL 567-0014 (01/2007)
(Street Number)
Printed on Recycled Paper
EXP. DATE
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Illinois Department of Revenue
RL-1
Liquor Tax Statement of Liability
Read this information first
You must complete this form and submit it to us with your completed bond forms.
Step 1: Identify your business
Name ____________________________________________
DBA
IBT no. ____ ____ ____ ____ – ____ ____ ____ ____
____________________________________________
Address __________________________________________
Number and street
__________________________________________________
City
State
ZIP
Step 2: Estimate your average monthly tax liability and bond amount
1 What is your estimated average monthly liquor tax liability?
2 Multiply Line 1 by 2. This is your bond amount.
$______________________
$______________________
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
Step 3: Sign below
Mail this form to
Under penalty of perjury, I state that I have examined this form
and, to the best of my knowledge, it is true, correct, and complete.
__________________________________________________
Signature
Date
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19039
SPRINGFIELD IL 62794-9039
If you have any questions, call us at 217 782-6997.
RL-1 (N-8/95) IL-492-3536
SOY-BASE INK
RECYCLED PAPER
Illinois Department of Revenue
RL-1
Liquor Tax Statement of Liability
Read this information first
You must complete this form and submit it to us with your completed bond forms.
Step 1: Identify your business
Name ____________________________________________
DBA
IBT no. ____ ____ ____ ____ – ____ ____ ____ ____
____________________________________________
Address __________________________________________
Number and street
__________________________________________________
City
State
ZIP
Step 2: Estimate your average monthly tax liability and bond amount
1 What is your estimated average monthly liquor tax liability?
2 Multiply Line 1 by 2. This is your bond amount.
$______________________
$______________________
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
Step 3: Sign below
Mail this form to
Under penalty of perjury, I state that I have examined this form
and, to the best of my knowledge, it is true, correct, and complete.
__________________________________________________
Signature
RL-1 (N-8/95) IL-492-3536
Date
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19039
SPRINGFIELD IL 62794-9039
If you have any questions, call us at 217 782-6997.
SOY-BASE INK
RECYCLED PAPER
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Illinois Dept. of Revenue
Directions for completing:
• REG-4-A (Financial Responsibility Bond); and
• REG-4-D (Financial Institution Irrevocable Letter of Credit Bond)
You must provide this information to the bank or insurance company that will be providing your bond. A separate bond is
required for each location. You will not be issued a certificate of registration and cannot be legally registered to do business
in Illinois until we receive your bond. Your bond can be in the form of:
Insurance bonds:
Form REG-4-A, Financial Responsibility Bond, must be completed entirely by your insurance company. Your business’
name and address must be identical to the information you have registered with us. The insurance company issuing your
bond must:
• Sign;
• Stamp their insurance seal;
• Assign a bond number; and
• If applicable, attach their power of attorney stating the attorney-in-fact’s name.
All of your business’ owners, officers, or partners must sign the bond. If you are a corporation, the president and secretary must
sign the bond. You must also affix your corporate seal. Note: The original bond and power of attorney must be sent to us.
Letter of Credit:
Form REG-4-D, Financial institution Irrevocable Letter of Credit Bond, must be completed entirely by your bank if you are
providing a bank letter of credit. Your business’ name and address must be identical to the information you have registered
with us. The bank issuing your letter of credit must:
• Stamp their bank seal; and
• Send to us the original bank letter of credit containing the seal.
Note: The Letter of Credit must be signed by an authorized officer of the banking institution.
Certificates of Deposit:
Any bank may issue you a Certificate of Deposit to satisfy your bond requirements. A Certificate of Deposit must:
• Be made payable to the Director, Illinois Department of Revenue;
• State that the Certificate of Deposit is automatically renewable;
• Have a maturity date of 12 months or less;
• Have your business’ name and identification number (i.e. FEIN or Social Security number).
If you prefer, you can send us a cashier’s check and we will purchase the Certificate of Deposit for you. Note: The original
Certificate of Deposit must be sent to us, receipts are not acceptable.
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Illinois Department of Revenue
REG-4-A
Financial Responsibility Bond
Part 1: Financial responsibility bond type and number
a
Bond type:
b
Financial responsibility bond number:________________________
Part 2: Taxpayer and financial institution information
We,
__________________________________________________________________________________ (as principal)
Taxpayer's name and address
and
__________________________________________________________________________________ (as surety)
Name and address of surety
are bound to the people of the State of Illinois in the penal sum of $_________________.
heirs, executors, administrators, successors, and assigns to the payment of this amount.
We hereby bind ourselves, our
The condition of this bond is that if the principal (taxpayer) identified above, who has applied for the tax responsibility
(bond type) identified above, in Part 1, pays to the Illinois Department of Revenue (IDOR) all amounts becoming due from the
principal (taxpayer) under this law, then the bond will become void; otherwise, the bond will remain in full force.
The surety identified above may conditionally cancel this bond at any time by filing a written notice with IDOR by registered or
days. However, the surety is not discharged from any liability previously accrued under this bond or that
certified mail within
may accrue before the days expires.
Part 3: Financial responsibility bond signatures and seal requirements
We have signed and sealed this bond on __ __/__ __/__ __ __ __,
You must attach a power of attorney.
(Principal's seal)
to be effective __ __/__ __/__ __ __ __.
(Surety's seal)
_______________________________________________
_________________________________________________
Principal's (taxpayer) signature
Surety's signature
_______________________________________________
_________________________________________________
Attorney-in-fact's signature
_______________________________________________
Countersigned by
President's or co-partner's signature
_______________________________________________
_________________________________________________
Corporate secretary's signature
Agent for surety
_________________________________________________
Number and street
_________________________________________________
City
State
ZIP
For official use only
Date approved: __ __/__ __/__ __ __ __
Month
Day
Year
_________________________________________________
IDOR Director's signature
License number:________________________________
REG-4-A (R-01-04)
IL-492-2364
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Illinois Department of Revenue
REG-4-D
Financial Institution Irrevocable Letter of Credit Bond
Part 1: Financial institution letter of credit bond type and number
a
Bond type:
b
Financial institution irrevocable letter of credit number:_________________________
c
Bond amount: $____________________________
Part 2: Taxpayer and financial institution information
Taxpayer:
_______________________________________________
Name
Financial institution:
_________________________________________________
Name
_______________________________________________
Street address
_________________________________________________
Street address
_______________________________________________
City
State
ZIP
_________________________________________________
City
State
ZIP
Part 3: Effective and maturity date of bond
Effective date: ____ ____ ________
Month Day
Maturity date: ____ ____ ________
Year
Month Day
Year
Part 4: Bond conditions
If the taxpayer identified above, in Part 2, fails to pay the Illinois Department of Revenue (IDOR) all moneys, including penalties and
interest, due under this bond type's tax act, IDOR is authorized to draw drafts on demand against this irrevocable letter of credit.
The sum of this irrevocable letter of credit cannot exceed the bond amount above, in Part 1, and drafts drawn against it are
payable on demand. This letter of credit is issued for a period of one year and will be renewed automatically for successive one year
periods unless IDOR receives a written notice of cancellation 30 days prior to the maturity date.
Part 5: Financial institution officer information
The undersigned officer of the financial institution identified above, in Part 2 is duly authorized by the Board of Directors to execute
this irrevocable letter of credit; and this financial institution will honor all drafts on demand. The name of the authorized financial
institution officer, title and signature are required.
Name: ________________________________________
Title: ____________________________________________
Signature:____________________________________________________________________________
Part 6: Financial institution seal
The official seal of the financial institution must be affixed below.
For official use only
Date approved: __ __/__ __/__ __ __ __
Month
Day
Year
_________________________________________________
IDOR Director's signature
License number:_____________________________
REG-4-D (R-01/04)
IL-492-3272
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