Illinois Department of Revenue Schedule REG-1-R Responsible Party Information Attach to Form REG-1 or fax to us at 217 785-6013. Business name: _________________________________________ FEIN: Contact for this schedule: __________________________________ SSN: ______ - __________________ _________ - ______ - ____________ (Proprietorship only) Phone: (__ __ __) ___ ___ ___ - ___ ___ ___ ___ Read this information first. Complete this schedule and attach it to Form REG-1, Illinois Business Registration Application, 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. Step 1: Identify the person(s) responsible for filing your business’ returns and paying all tax due Printed legal name:_______________________________________ SSN: _________ - ______ - ____________ Legal address: __________________________________________ Phone: (_____) ______ - ___________ Check all for which you are responsible: ˆ ˆ ˆ Sales and use taxes and fees Motor vehicle renting tax Withholding income tax ˆ ˆ ˆ Motor fuel and related taxes ˆ 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:_______________________________________ SSN: _________ - ______ - ____________ Legal address:__________________________________________ Phone: (_____) ______ - ___________ Check all for which you are responsible: ˆ ˆ ˆ Sales and use taxes and fees Motor vehicle renting tax Withholding income tax ˆ ˆ ˆ Motor fuel and related taxes ˆ 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:_______________________________________ SSN: Legal address:__________________________________________ Phone: (_____) ______ - ___________ ˆ ˆ ˆ Sales and use taxes and fees Motor vehicle renting tax Withholding income tax ˆ ˆ ˆ _________ - ______ - ____________ Motor fuel and related taxes ˆ 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:___/___/______ Schedule REG-1-R (R-04/10) American LegalNet, Inc. www.FormsWorkFlow.com