Illinois Department of Revenue REG-3-D Request for Signature Read this information first Form REG-3-D must be filled out in its entirety to complete your registration or to change information previously provided for a registered business. Signature stamps are not acceptable. You can fax Form REG-3-D to us at 217 785-6013. If you prefer, mail your completed Form REG-3-D to the Central Registration Division, Illinois Department of Revenue, PO Box 19030, Springfield Illinois 62794-9030. Step 1: Provide your business or organization information Internet applicants must provide the application code. If you are changing information for a previously registered business, tell us your Illinois Business Tax number (IBT no.). ____________________________________________________________ (_____)_____ - ______________ Name of your business Daytime telephone ____________________________________________________________ ________-________-________-______ Street address of your business Application code (e.g., A999-A999-A999-9999) ____________________________________________________________ ___ ___ ___ ___ - ___ ___ ___ ___ City Illinois Business Tax number (IBT no.) State ZIP Step 2: Sign here Under penalties of perjury, I certify I have examined all the information provided for my registration or renewal application and, to the best of my knowledge, it is true, correct, and complete. Signature:_____________________________________________________ Date: ___/___/_______ Printed name: __________________________________________________ Title: ___________________________ Address: ___________________________________________________________________________________________ Step 3: Tell us the person(s) responsible for filing returns and paying taxes and fees due The tax responsibilities listed below require the person who will be responsible for filing tax returns and paying the tax or fee due to complete the following information and sign. If you need to identify more, attach additional sheets using a similar format. ____________________________________________________________ (_____)_____ - ______________ Name Daytime telephone ____________________________________________________________ ___ ___ ___-___ ___-___ ___ ___ ___ Address Social Security number (SSN) Check all tax types for which you are responsible for filing returns and paying the tax or fee due. ___ Withholding Income Tax ___ Motor Vehicle Renting Tax ___ Motor Fuel Tax ___ Sales, Service & Use Taxes ___ Hotel Operators' Tax ___ Environmental Impact Fee & Underground Storage Tax Under penalties of perjury, I state that I am personally responsible for filing and paying the taxes and fees listed above. ______________________________________________ Signature ____/____/______ Date -------------------------------------------------------------------------------------____________________________________________________________ (_____)_____ - ______________ Name Daytime telephone ____________________________________________________________ ___ ___ ___-___ ___-___ ___ ___ ___ Address Social Security number (SSN) Check all tax types for which you are responsible for filing returns and paying the tax or fee due. ___ Withholding Income Tax ___ Motor Vehicle Renting Tax ___ Motor Fuel Tax ___ Sales, Service & Use Taxes ___ Hotel Operators' Tax ___ Environmental Impact Fee & Underground Storage Tax Under penalties of perjury, I state that I am personally responsible for filing and paying the taxes and fees listed above. ______________________________________________ Signature ____/____/______ Date This form is authorized by 20 ILCS 687/6-1 et seq.; 35 ILCS 5/1 et seq., 105/1 et seq., 110/1 et seq., 115/1 et seq., 120/1 et seq., 130/1 et seq., 135/1 et seq., 143/10-1 et seq., 145 et seq., 155/1 et seq., 173/5-1 et seq., 505/1 et seq., 510/1 et seq., 615/1/et seq., 620/1 et seq., 625/1 et seq., 630/1 et seq.; 35 ILCS 635/1 et seq., 636/5-1 et seq., 640/2-1 et seq.; 230 ILCS 20/1 et seq., 25/1 et seq., 30/1 et seq.; 235 ILCS 5/1-1 et seq.; 305 ILCS 20/5 et seq.; 415 ILCS 125/301 et seq. Disclosure of this information may be REQUIRED. Failure to provide information could result in this form not being processed and possible penalties. This form has been approved by the Forms Management Center. IL-492-0001 REG-3-D (R-06/04) American LegalNet, Inc. www.FormsWorkflow.com