Illinois Department of Revenue Schedule REG-1-O Owner and Officer Information Mail your completed Schedule REG-1-O to: Central Registration Division, Illinois Department of Revenue, PO Box 19476, Springfield, IL 62794-9476 Read this information first - First time registrants - Attach this schedule to Form REG-1. If your organization is a: Proprietorship Partnership Corporation or S Corp Trust or estate Not-for-profit organization Limited liability company Governmental unit then complete Step 2 to identify: — the owner (if husband/wife or civil union, enter both individuals’ information) — each general partner — the president, secretary, and treasurer — each trustee or executor — the president, secretary, or treasurer — each manager and member — one contact person (for example, the liaison) Step 1: Identify your business or organization Business name: _________________________________________ FEIN: ______ - __________________ SSN: _________ - ______ - ____________ (Proprietorship only) Contact information for person completing this schedule: Name: _________________________________________________ Phone: (______) ______ - ____________ Step 2: Identify your owners and officers 1 Individuals - For each individual required, complete the following information (including the Social Security number). a ___________________________________ _________________ Name c Title Home address - No PO Box number City State _________________ Name ______________________________________________________ ___________________________________ Title ______________________________________________________ ZIP Home address - No PO Box number ____ / ____ / ________ (______) ______ - ________ ____ / ____ / ________ (______) ______ - ________ Date of birth Phone Date of birth Phone City State ZIP _______ - _____ - _________ Ownership percentage: ______ b _______ - _____ - _________ Ownership percentage: ______ Social Security number Social Security number ___________________________________ _________________ Name d Title Home address - No PO Box number City State _________________ Name ______________________________________________________ ___________________________________ Title ______________________________________________________ ZIP Home address - No PO Box number ____ / ____ / ________ (______) ______ - ________ ____ / ____ / ________ (______) ______ - ________ Date of birth Phone Date of birth Phone City State ZIP _______ - _____ - _________ Ownership percentage: ______ _______ - _____ - _________ Ownership percentage: ______ Social Security number Social Security number 2 Businesses - For each business that is an owner, complete the following information (including the federal employer identification number (FEIN)). a ___________________________________ ____-_____________ Name c FEIN ___________________________________ ____-_____________ Name FEIN ______________________________________________________ ______________________________________________________ Legal address Legal address ______________________________________________________ ______________________________________________________ City City (______) ______ - ________ State ZIP Ownership percentage: ______ Phone ___________________________________ ____-_____________ Name ZIP (______) ______ - ________ Ownership percentage: ______ Phone b State FEIN d ___________________________________ ____-_____________ Name FEIN ______________________________________________________ ______________________________________________________ Legal address Legal address ______________________________________________________ ______________________________________________________ City City State ZIP State ZIP (______) ______ - ________ Ownership percentage: ______ (______) ______ - ________ Ownership percentage: ______ Phone Phone Schedule REG-1-O (R-07/12) American LegalNet, Inc. www.FormsWorkFlow.com