Division of Medical Cannabis
Dispensary Sale Surcharge Exemption Form
Printed by Authority of the State of Illinois IOCI 21-175
Dispensary Name: District #:
Address: City: ZIP Code:
Reason(s) For Transfer/Sale of Registration
Will registrant be unable to transact business if transfer/sale is not completed? Reason
Reason transfer/sale of the registration is “in the best interest of Illinois qualifying patients”
I, the undersigned, certify the information provided on this form is true and accurate to the best of my knowledge. I
understand that the Illinois Department of Public Health will review the information to determine whether the sale/transfer
meets the provisions of IAC 100.2060(e)(1)(c) and thus exempt from transaction surcharge.
Name of Seller:
Date:Signature of Seller:
Mail completed form to:
Illinois Department of Public Health
Division of Medical Cannabis
535 W. Jefferson St.
Springfield, IL 62761-0001
Office Use Only
IDPH Signature:
Approved Denied
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