Illinois Department of Revenue
Schedule REG-1-R Responsible Party Information
Read this information first - First time registrants - Attach this schedule to Form REG-1.
Complete this schedule 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. You can fax Schedule REG-1-R to us at 217 785-6013.
Step 1: Identify your business or organization
Business name: __
_____________________________________________________
FEIN: ______ - __________________
If your business is a corporation, are you publicly traded? ____ Yes ____ No SSN: _________ - ______ - ____________
If “Yes”, provide the ticker symbol:
________________
(Proprietorship only)
Contact for this schedule:
_______________________________________
Phone: (______) ______ - _________
Step 2: 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:
Sales and use taxes and fees Motor fuel and related taxes Marketplace Facilitator
Motor vehicle renting tax Unemployment insurance Withholding income tax
Excise taxes and fees - Identify tax/fee: _______________________________ Other: __________________________
All taxes and fees
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:
Sales and use taxes and fees Motor fuel and related taxes Marketplace Facilitator
Motor vehicle renting tax Unemployment insurance Withholding income tax
Excise taxes and fees - Identify tax/fee: _______________________________ Other: __________________________
All taxes and fees
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:
Sales and use taxes and fees Motor fuel and related taxes Marketplace Facilitator
Motor vehicle renting tax Unemployment insurance Withholding income tax
Excise taxes and fees - Identify tax/fee: _______________________________ Other: __________________________
All taxes and fees
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: ___ / ___ / ______
Mail your completed schedule, with any required attachments to: CENTRAL REGISTRATION DIVISION 3-222
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19030
SPRINGFIELD IL 62794-9030
Schedule REG-1-R (R-12/19)
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this information is required. Failure to provide
information may result in this form not being processed and may result in a penalty. Printed by the authority of the State of Illinois, Web only - One copy
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
