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Business DBA Name ___________________________________________________
Location Address ______________________________________Decatur, IL _____________**
Location Phone ______________________ Cell Number __________________
This location is a (Check one) Retail Dealer Bulk User Date Opened _____________
For ABOVE ground tanks only: Quantity____ | Size __________gal | Contents Gasoline or Diesel
Illinois Business Tax (IBT) # __ __ __ __ - __ __ __ __ or FEIN __ __ - __ __ __ __ __ __ __
Owner/Corp/Partnership Name ____________________________________________________
Mailing Address ______________________________________________________
City ___________________________ State ______ Zip ____________
Owner Phone Number _________________________ E-mail ____________________________
Business Type: Sole Proprietorship Corporation LLC Partnership Other _____________
specify
Owner (s), Corporate Officers, or Partners: (Attach listing if more space is needed)
______________________________ _____________________ ________________________________ _______________
______________________________ _____________________ ________________________________ _______________
______________________________ _____________________ ________________________________ _______________
Name Title Home Address Phone
**Multiple location address listing (Please attach listing if more space is needed)
_________________________________ ______________________________ ____________________
_________________________________ ______________________________ ____________________
_________________________________ ______________________________ ____________________
Business DBA Name Address Location Phone
Under penalties as provided by law, I declare that to the best of my knowledge and belief, the information on
this form is true, correct and complete. Any changes must be reported within two weeks. Failure to submit a
registration, report or update registration for changes is a violation of City Code.
_____________________________________________ ______________
Signature of Owner/Officer Date
_____________________________________________ ____________________________________
Print name Title
Mail or Fax completed and signed form to:
City of Decatur Questions? Call 217-424-2854
Budget & Revenue Officer
#1 Gary K Anderson Plaza City website and tax forms:
Decatur, IL 62523 www.decaturil.gov
FAX # 217-424-2717
CITY OF DECATUR
Local Motor Fuel Tax Registration Form
