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 DISTRIBUTOR/ IMPORTING DISTRIBUTOR/FOREIGN IMPORTER LIQUOR LICENSE DEFINITION: In order to obtain any class of distributor’s license, an applicant must post a $1,000 bond with the Illinois Department of Revenue as an assurance that all liquor taxes will be paid. In order to satisfy the bond requirement, the applicant must complete and submit one of the following three types of tax bonds along the application. The applicant may submit a check for $1,000 made payable to the Illinois Department of Revenue, obtain a bonding certificate from a local insurer or obtain a letter of credit from a bank. If direct payment is made to the Department of Revenue, a refund will be issued after two full calendar years has elapsed, provided that all applicable taxes have been and continue to be paid. If applying for an importing distributor’s license, a foreign importer’s license or both only one bond is required. All licensed distributors are required to file the enclosed Registration Statement (IL 567-0014). The Registration Statement authorizes the distributor to resell a trademark/brand name product at wholesale within a specified geographic territory for a specified period of time. All distributors are required to file a “Liquor Tax Statement of Liability” (Form RL-1) with the Illinois Department of Revenue to report monthly tax liability. FEE: A. DISTRIBUTOR LICENSE $270.00 A distributor license, granted pursuant to the Illinois Liquor Control Act, permits an entity other than a manufacturer, non-resident dealer, or retailer to purchase, store, possess, or warehouse any alcoholic liquors for resale or reselling at wholesale whether within or without Illinois. Please include the following REQUIRED supporting documents: 1) A copy of Basic Permit. Visit www.ttb.gov to download the Federal Tax and Trade Bureau’s F 5100.24 application form (visit www.ttb.gov or call 1-877-882-3277 for further info); 2) An appointment letter from the manufacturer where they have appointed the applicant as their primary importer or duly registered agent. 3) A Tax Bond acquired through one of the following enclosed documents: • RL-1 Tax Statement of Liability; • REG-4-A Financial Responsibility Bond (Liquor Gallonage Tax Bond) Certificate of Deposit; or • REG-4-D Financial Institution Irrevocable Letter of Credit Bond. 4) The enclosed Registration Statement (if applicable). 5) If you have chosen a warehouse location that stores product for other Illinois Licensed Distributors, the warehouse owner/operator should obtain a warehouseman certificate. See enclosed REG-1 form. 6) If you are leasing the property, please submit a lease . If you own the property, please submit a deed or other proof of ownership document. The ILCC will schedule an inspection of the warehouse once we receive your completed application. PROCESSING TIME FOR A DISTRIBUTOR LICENSE IS GENERALLY BETWEEN 3-8 WEEKS. IL 567-0015-A (09/2010) Printed on Recycled Paper PAGE 1 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com B. IMPORTING DISTRIBUTOR’S LICENSE FEE: $25.00 An importing distributor’s license, granted pursuant to the Illinois Liquor Control Act, permits an already licensed Illinois distributor to import into this State, from any point in the United States outside of Illinois from an Illinois-licensed, non-resident dealer or foreign importer, whether for itself or another, any alcoholic liquors for sale or resale, or for use in the manufacture, preparation or compounding of products other than alcoholic liquors, or for importing more than one gallon of such liquors from any point in the United states outside of Illinois for consumption in any one calendar year. A licensed importing distributor may purchase alcoholic liquor in barrels, casks or other bulk containers, and the bottling of such alcoholic liquors before resale thereof, but all bottles or containers so filled shall be sealed, labeled, stamped and otherwise made to comply with all provisions, rules and regulations governing manufacturers in the preparation and bottling of alcoholic liquors. IMPORTANT: If you are applying for an importing distributor’s license you must purchase your product from a licensed Illinois non-resident dealer or foreign importer. To apply for the Importer’s License you must submit the following: 1) Distributor Application: $270 2) Importing Distributor’s Application: $25 3) An appointment letter from the manufacturer where they have appointed the applicant as their primary importer or duly registered agent. 4) ONE of the enclosed bond forms: • RL-1 Tax Statement of Liability; • REG-4-A Financial Responsibility Bond (Liquor Gallonage Tax Bond) Certificate of Deposit; or • REG-4-D Financial Institution Irrevocable Letter of Credit Bond. 5) Copy of your Federal Basic Permit. Questions about your Federal Basic Permit should be directed to the TTB at www.ttb.gov or 1-800-937-8864. 6) Total fees for distributors, importing distributors and foreign importing distributors is $295. C. FOREIGN IMPORTER’S LICENSE FEE: $25.00 A foreign importer’s license, granted pursuant to the Illinois Liquor Control Act, permits an already-licensed Illinois distributor to import into Illinois from any point outside of the United States, any alcoholic liquors other than bulk, for sale to a licensed importing distributor. A foreign importer shall not hold a non-resident dealer license. A foreign importer shall be required to purchase alcoholic liquor from a non-resident dealer within the United States or any other person located outside the United States. IMPORTANT: If you are applying for a liquor license to import AND distribute liquor directly from OUTSIDE (Foreign Country) the United States into Illinois you will need to provide the information listed below in STEPS 1-7. To apply for the Foreign Importer’s License you must submit the following: 1) Distributor Application: $270 2) Importing Distributor’s Application: $25 3) Foreign Importer’s Application: $25 4) An appointment letter from the manufacturer where they have appointed the applicant as their primary importer or duly registered agent. 5) ONE of the enclosed bond forms. • RL-1 Tax Statement of Liability; • REG-4-A Financial Responsibility Bond (Liquor Gallonage Tax Bond) Certificate of Deposit; or • REG-4-D Financial Institution Irrevocable Letter of Credit Bond. 6) Copies of your Federal Label Approvals and Federal Basic Permits. The Federal Label Approvals must be issued in the name of the applicant and must have the Illinois warehouse or business address. Questions about Federal Label Approvals and Federal Basic Permits should be directed to the TTB at www.ttb.gov or 1-800-937-8864. 7) Total fees for distributors, importing distributors and foreign importing distributors is $320. IL 567-0015-A (09/2010) PAGE 2 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED EXPIRATION DATE † COUNTER Application for State of Illinois Distributor/Importing Distributor/Foreign Importer Liquor License 1. APPLICANT - CORPORATE INFORMATION A. If you want your renewal application, license certificate, and other ILCC correspondence sent to your “corporate” address, please check the box to the right. † 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 (SALES TAX ACCOUNT NUMBER) Enter the eight-digit Illinois Dept. of Revenue Business Tax (Sales Tax Account) Number. YOU MUST HAVE THIS NUMBER IN ORDER FOR A LICENSE TO BE ISSUED. If you need to obtain this number, www.tax.illinois.gov, click on "Businesses," and then “Business Registration” to to obtain this number. If you have any quesitons, call 217-785-3707. 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. CORPORATE NAME (Also list trade or business name, if different from corporate name) Enter the name of the corporation (Illinois, national, or foreign) partnership or limited liability company in this box. CORPORATE NAME F . DBA NAME ADDRESS Enter the street address, city, state, and Zip Code of the sole proprietorship, corporation, etc.. ADDRESS IL 567-0015-A (09/2010) CITY STATE ZIP CODE PAGE 3 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 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 copartnership, 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. A. B. C. D. E. † † † † † ASSUMED NAME DATE FILED WITH COUNTY CLERK: PARTNERSHIP DATE OF FORMATION: ILLINOIS CORPORATION DATE OF INCORPORATION: FOREIGN CORPORATION STATE OF INCORPORATION: LIMITED LIABILITY COMPANY DATE FORMED: DATE QUALIFIED TO DO BUSINESS IN IL: 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 for each individual applicant, sole proprietor, partner, corporate officer or director (whether or not they own any stock), shareholder owning in the aggregate stock equal to or more than 5% , (including officers, directors and shareholders with stock 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 hold less than a 5% interest. 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. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. B. 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 NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. E. DATE OF BIRTH TITLE/POSITION HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. D. DATE OF BIRTH CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. C. DATE OF BIRTH HOME ADDRESS CITY TITLE/POSITION AREA CODE/TELEPHONE NO. TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST IL 567-0015-A (09/2010) STATE STATE STATE STATE ZIP % OWNED ZIP % OWNED ZIP % OWNED ZIP % OWNED % PAGE 4 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 4. MISCELLANEOUS INFORMATION A. WAREHOUSING If any of your inventory is warehoused, provide the name, street address, city, state, Zip Code and county of the warehouse. NOTE: Warehouse inspection will be conducted prior to the issuance of your liquor license. ADDRESS B. 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 AREA CODE/TELEPHONE NO. STATE CITY ADDRESS ZIP CODE COUNTY 5. LICENSE HISTORY A. 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: IL 567-0015-A (09/2010) PAGE 5 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 6. ELIGIBILITY QUESTIONS These questions apply to the applicant and any other person listed under Section 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. 6-18 † 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 567-0015-A (09/2010) TITLE/POSITION DATE PAGE 6 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 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 GEOGRAPHICAL TERRITORY TIME PERIOD 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 (01/2006) (Street Number) EXP. DATE American LegalNet, Inc. www.FormsWorkFlow.com 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. American LegalNet, Inc. www.FormsWorkFlow.com 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 certified mail within days. However, the surety is not discharged from any liability previously accrued under this bond or that 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 American LegalNet, Inc. www.FormsWorkFlow.com 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 a 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; and ❒ have your business' name and identification number (i.e., Federal Employer's Identification number (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. REG-4-A (R-01-04) IL-492-2364 American LegalNet, Inc. www.FormsWorkFlow.com 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 American LegalNet, Inc. www.FormsWorkFlow.com 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 a 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; and ❒ have your business' name and identification number (i.e., Federal Employer's Identification number (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. REG-4-D (R-01/04) IL-492-3272 American LegalNet, Inc. www.FormsWorkFlow.com 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: ____________________________________________ IBT no. ____ ____ ____ ____ – ____ ____ ____ ____ DBA: ____________________________________________ 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 two. This is your bond amount. $______________________ Note: The minimum bond amount is $1,000 and the maximum amount is $100,000. Step 3: Sign below If you have any questions, call us at 217 782-6997. 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 (R - 05/08) IL-492-3536 Date SOY-BASE INK RECYCLED PAPER American LegalNet, Inc. www.FormsWorkFlow.com Illinois Department of Revenue REG-1 Illinois Business Registration Application Register faster on-line at tax.illinois.gov. If you are already registered and need to make changes (e.g., adding a location, changing officer information), call us weekdays between 8:00 a.m. and 5:00 p.m. at 217 785-3707. Step 1: Identify your business or organization 6 Check the organization type that applies to you: 1 Federal employer identification number (FEIN) Proprietorship. Check if owned by husband and wife: _____ Partnership Trust or estate Corporation S Corp (Subchapter S Corporation) Governmental unit Not-for-profit organization Limited liability company (LLC) treated as a ____ Corporation ____ Partnership ____ Proprietorship Check here if disregarded: _____ FEIN: ______ - __________________ If you are a proprietorship, provide the Social Security number (SSN) under which taxes will be filed. SSN: _________ - ______ - ____________ 2 Legal business name - if proprietorship, see instructions. ___________________________________________________ 3 Doing-business-as (DBA), assumed, or trade name, if different from Line 2. ___________________________________________________ 4 Primary or legal business address. 7 Illinois Secretary of State identification (corporate or file) number: ___ - ___ ___ ___ ___ - ___ ___ ___ - ___ ___________________________________________________ Street address - No PO Box number Apartment or suite number ___________________________________________________ City State ZIP Check here if this is your only Illinois location. If you have more Illinois locations, complete Schedule REG-1-L. 8 Is your business part of a unitary group? ___ Yes ___No If “Yes”, provide the FEIN of your designated agent (the person responsible for filing your Illinois income tax return): FEIN: ______ - __________________ 9 Identify a contact person regarding your business. 5 Mailing address if different from the address above. ___________________________________________________ Name: __________________________________________ ___________________________________________________ Phone: (______) ______ - ________ Ext.: __________ In-care-of name Street address or PO Box number Apartment or suite number ___________________________________________________ City State ZIP FAX: (______) ______ - ________ Email address: _____________________________________ Step 2: Identify your owners, officers, and general partners - if a limited liability company, include the manager 10 Identification depends on your organization type. If you need to identify more, attach Schedule REG-1-O. Individuals: a ___________________________________ _________________ Name d Title _______________________________ (____) _____ - ________ _______________________________ (____) _____ - ________ Home street address - No PO Box number _________________ Name Title ___________________________________ Home street address - No PO Box number Telephone Telephone ______________________________________________________ ______________________________________________________ City ____ / ____ / ________ Date of birth b State City ZIP ____ / ____ / ________ ______ - _____ - _________ SSN Date of birth _________________ Name Title a _______________________________ (____) _____ - ________ City Date of birth ______ - _____ - _________ SSN State ___________________________________ ____-_____________ Name FEIN ______________________________________________________ Telephone Legal address ______________________________________________________ ____ / ____ / ________ ZIP Businesses that are owners, managers, or general partners: ___________________________________ Home street address - No PO Box number State ______________________________________________________ ZIP City ______ - _____ - _________ State ZIP (______) ______ - ________ SSN Telephone c ___________________________________ _________________ Name Title _______________________________ (____) _____ - ________ Home street address - No PO Box number Telephone ____ / ____ / ________ Date of birth State ___________________________________ ____-_____________ Name ______________________________________________________ ZIP ______________________________________________________ City State ______ - _____ - _________ SSN (______) ______ - ________ Telephone REG-1 (R-11/09) FEIN Legal address ______________________________________________________ City b American LegalNet, Inc. www.FormsWorkFlow.com ZIP Step 3: Tell us about your business activities 11 Describe your business activities:_________________________ ______________________________________________ ___________________________________________________ 12 Will you have employees? ____ Yes ____ No Renting or leasing: ____ Hotel ____ Vehicles. Check the terms of your agreements (both may apply): ____ Longer than 12 months Tell us when your Illinois payroll will begin: ____/____/_____ ____ 12 months or less Utilities - Check your utility and type of sales and services: 13 Check all that apply to your type of business. ____ Electricity: ____ General merchandise: ____ Retail ____ Wholesale Do you estimate your monthly sales tax liability to be over $200? ____ Yes ____ No ____ Resale ____ Natural gas: Sales: ____ Retail ____ Retail ____ Resale ____ Telecommunications: ____ Retail ____ Resale ____ Water or sewer services Are you a utility cooperative? ____ Yes ____ No Are you a municipality? ____ No ____ Sales to Illinois customers from out-of-state Check here if you have an Illinois presence. ____ Soft drinks in sealed containers ____ Yes Other: ____ Vehicle, watercraft, aircraft, or trailer ____ Liquor warehousing - Attach Schedule REG-1-L. ____ From vending machines ____ Sales or delivery of tires . Do you always pay the Tire User Fee to your supplier? ____ Yes ____ No Tell us how many machines: ________ ____ Liquor at retail (bar, tavern, liquor store, etc.) ____ Dry cleaning solvents ____ Cigarettes: ____ Retail ____ Wholesale ____ Coin-operated amusement devices ____ Tobacco products: ____ Retail ____ Wholesale ____ Purchase electricity for non-residential use and want to pay the tax to IDOR. ____ Motor fuel/fuel: ____ Retail ____ Wholesale Services: Do you transfer items as part of your service? ____ Yes ____ No ____ Purchase natural gas from out-of-state for my own use and want to pay the tax to IDOR. Identify your delivering supplier(s): _________________________________________ ____ Not listed. Identify: __________________________ Use: If you purchase merchandise for your use in Illinois, does your supplier collect the Illinois sales tax? ____ Yes ____ No 14 When will (did) these activities begin? ____/____/_____ Step 4: Check any schedule attached (not all applicants are required to complete schedules) Schedule REG-1-L Schedule REG-1-O Other information Step 5: Sign below 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 all taxes due unless Schedule REG-1-R, Responsible Party Information, is attached to this application or forwarded to the department. Check here if you are attaching or forwarding Schedule REG-1-R: Signature: __________________________________________ Title:________________________________ Date:___/___/______ Printed name: __________________________________________ SSN: ________ - _______ - _____________ Address: __________________________________________ Telephone: (_____) _______ - ___________ Step 6: Mail your application Mail your completed application and attachments (if applicable) to us at CENTRAL REGISTRATION DIVISION ILLINOIS DEPARTMENT OF REVENUE PO BOX 19476 SPRINGFIELD IL 62794-9476 This form is authorized by 20 ILCS 687/6 et seq.; 35 ILCS 5/1et seq.,105/1et seq., 110/1et seq., 115/1et seq., 120/1et seq., 130/1et seq., 135/1 et seq., 143/10-1et seq., 155/1 et seq., 415/1 et seq., 505/1et seq., 510/1et seq., 615/1et seq., 620/1 et seq., 625/1et seq., 630/1et seq., 635/1et seq.; 640/2-1 et seq.; 230 ILCS 20/1 et seq.; 25/1et seq., 30/1et seq.; 235 ILCS 5/1-1 et seq.; 305 ILCS 20/5 et seq., 687/6-1 et seq.; 415 ILCS 125/301et 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-1 (R-11/09) American LegalNet, Inc. www.FormsWorkFlow.com Illinois Department of Revenue Schedule REG-1-L Illinois Business Site Location Information Attach to Form REG-1. Business name: _________________________________________ FEIN: Contact for this schedule:_________________________________ SSN: ______ - __________________ _________ - ______ - ____________ (Proprietorship only) Phone: (__ __ __) ___ ___ ___ - ___ ___ ___ ___ Read this information first. Complete this schedule if you are registering as a new business that will do business from an Illinois location. You must identifiy all Illinois locations, including the one you may have identified on Form REG-1, Step 1, Line 4. In Illinois, some tax rates vary based upon the specific location of the business activities. Depending on your tax responsibilities, the location of your business will determine the tax rate that we will preprint on your return. We recognize three types of locations: Permanent - Examples include a building, warehouse, or storefront. To identify these, complete Step 1. Temporary - Examples include a fair, festival, or convention. To identify temporary locations, complete Step 2. Special events or seasonal sales (i.e., trade-shows, holiday sales, concession stands) should also complete Step 2. Changeable - A changeable location is one that constantly changes (i.e., door-to-door sales, home party sales). If you have changeable locations, complete Step 3. If you need to identify more, attach a separate sheet using a similar format. If you have previously registered and need to add a location, call us at 217 785-3707. Step 1: Identify each permanent location. DBA name:____________________________________________ DBA name:____________________________________________ Address: _____________________________________________ Address: _____________________________________________ Street address - No PO Box numbers Apt. or suite no. Street address - No PO Box numbers Apt. or suite no. _____________________________________________ _____________________________________________ City City State ZIP State ZIP County:______________________ If located within Madison or County:______________________ If located within Madison or St. Clair county, tell us your township: _______________________ St. Clair county, tell us your township: _______________________ Contact: ____________________ Phone: (____)____ - _______ Contact: ____________________ Phone: (____)____ - _______ Starting date for this location: ____/____/_______ Starting date for this location: ____/____/_______ Check your activities at this location: Check your activities at this location: Sales and use Vehicle renting Sales and use Vehicle renting Vehicle sales Telecommunications service Vehicle sales Telecommunications service Hotel rental Liquor warehousing Hotel rental Liquor warehousing Other: _______________________________________ Other: _______________________________________ DBA name:____________________________________________ DBA name:____________________________________________ Address: _____________________________________________ Address: _____________________________________________ Street address - No PO Box numbers Apt. or suite no. Street address - No PO Box numbers Apt. or suite no. _____________________________________________ _____________________________________________ City City State ZIP State ZIP County:______________________ If located within Madison or County:______________________ If located within Madison or St. Clair county, tell us your township: _______________________ St. Clair county, tell us your township: _______________________ Contact: ____________________ Phone: (____)____ - _______ Contact: ____________________ Phone: (____)____ - _______ Starting date for this location: ____/____/_______ Starting date for this location: ____/____/_______ Check your activities at this location: Check your activities at this location: Sales and use Vehicle renting Sales and use Vehicle renting Vehicle sales Telecommunications service Vehicle sales Telecommunications service Hotel rental Liquor warehousing Hotel rental Liquor warehousing Other: _______________________________________ Schedule REG-1- L (N-11/07) Other: _______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Step 2: Identify each temporary location Examples include a fair, festival, or special event. Seasonal sales (i.e., trade-shows, holiday sales, concession stands) are usually considered a temporary location. DBA name:____________________________________________ DBA name:____________________________________________ Address: _____________________________________________ Address: _____________________________________________ Street address - No PO Box numbers Apt. or suite no. Street address - No PO Box numbers Apt. or suite no. _____________________________________________ _____________________________________________ City City State ZIP State ZIP County:______________________ If located within Madison or County:______________________ If located within Madison or St. Clair county, tell us your township: _______________________ St. Clair county, tell us your township: _______________________ Contact: ____________________ Phone: (____)____ - _______ Contact: ____________________ Phone: (____)____ - _______ Starting date for this location: ____/____/_______ Starting date for this location: ____/____/_______ Sales and use Telecommunications service Sales and use Telecommunications service Vehicle sales Vehicle sales Other: ___________________________________________ Other: ___________________________________________ Check here if your business activities are seasonal or for a special event. Provide the following dates. Check here if your business activities are seasonal or for a special event. Provide the following dates. Starting: ____/____/_______ Starting: ____/____/_______ Ending: ____/____/_______ Ending: ____/____/_______ DBA name:____________________________________________ DBA name:____________________________________________ Address: _____________________________________________ Address: _____________________________________________ Street address - No PO Box numbers Apt. or suite no. Street address - No PO Box numbers Apt. or suite no. _____________________________________________ _____________________________________________ City City State ZIP State ZIP County:______________________ If located within Madison or County:______________________ If located within Madison or St. Clair county, tell us your township: _______________________ St. Clair county, tell us your township: _______________________ Contact: ____________________ Phone: (____)____ - _______ Contact: ____________________ Phone: (____)____ - _______ Starting date for this location: ____/____/_______ Starting date for this location: ____/____/_______ Sales and use Telecommunications service Sales and use Telecommunications service Vehicle sales Vehicle sales Other: ___________________________________________ Other: ___________________________________________ Check here if your business activities are seasonal or for a special event. Provide the following dates. Check here if your business activities are seasonal or for a special event. Provide the following dates. Starting: ____/____/_______ Starting: ____/____/_______ Ending: ____/____/_______ Ending: ____/____/_______ Step 3: Identify each changeable location A changeable location is one that constantly changes (i.e., door-to-door sales, home party sales). DBA name:____________________________________________ DBA name:____________________________________________ Municipality:___________________________________________ Municipality:___________________________________________ County:______________________ If located within Madison or County:______________________ If located within Madison or St. Clair county, tell us your township: _______________________ St. Clair county, tell us your township: _______________________ Starting date: ____/____/_______ Starting date: ____/____/_______ Schedule REG-1- L (N-11/07) American LegalNet, Inc. www.FormsWorkFlow.com