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APPLICATION FOR STATE OF ILLINOIS
NON-RESIDENT DEALER’S LIQUOR LICENSE
IL 567-0059-A (1/2019)
Page 1 of 4
DEFINITIONS: A Non-resident Dealer’s License shall permit such licensee to ship into and warehouse alcoholic liquor in this state from
any point outside of this state, and to sell such alcoholic liquor to Illinois-licensed foreign importers and importing distributors and to no
one else in this state; provided that said non-resident dealer shall register with the Illinois Liquor Control Commission each and every
brand of alcoholic liquor which it proposes to sell to Illinois licensees during the license period; and further provided that it shall comply
with all of the provisions of Section 5/6-9 of the Illinois Liquor Control Act with respect to registration of such Illinois licensees as may be
granted the right to sell such brands at wholesale. Please note that you must appoint an Illinois-licensed distributor (see page 3, item 10).
If you have agents, representatives or persons acting on your behalf in Illinois that sell or discuss pricing terms of alcoholic liquor
you are required to register each of these individuals by submitting forms IL 567-0053, Application for Registration - Manufacturer’s
Registered Agent, and IL 567-0054, Statement of Representation - Registration of Manufacturer’s Agent.
Please include the following REQUIRED supporting documents:
1) Registration Statement;
2) The following U.S. Department of the Treasurery Tax and Trade Bureau application forms. Please visit the TTB
website at www.ttb.gov or call 1 877 882-3277 for further information regarding these forms:
a) A copy of the Label
Approval. Visit www.ttb.gov to download the F 5100-31 application form
b) A copy of the Basic Permit. Visit www.ttb.gov to download the F 5100.24 application form
3) Schedule RL-26-L, Out-of-State Sellers’ Shipment Report. Please call the Illinois Department of Revenue at
217 785-2622 for more information or assistance (This is not a requirement);
4) Form IL 567-0053, Application for Registration - Manufacturer’s Registered Agent (if applicable*); and
5) Form IL 567-0054, Statement of Representation - Registration of Manufacturer’s Agent (if applicable*).
*If you have agents, representatives or persons acting on your behalf in Illinois that sell or discuss pricing terms
of alcoholic liquor, you are required to register each of these individuals by submitting the above two forms.
IMPORTANT NOTICE: THE ILLINOIS LIQUOR CONTROL COMMISSION IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY UNDER THE ILLINOIS LIQUOR CONTROL ACT
(235 ILCS 5/1 ET SEQ.). DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION WILL RESULT IN THE NON-ISSUANCE OF YOUR LICENSE.
A.
Currently licensed Illinois manufacturer: Class 1 - Distiller, Class 2 - Rectier or Class 3 - Brewer FEE: None
Non-resident dealer who is a manufacturer of less than 500,000 gallons per year combined plant total, FEE: $350.00
or agent thereof AND/OR primary U.S. importer exporting less than 500,000 gallons into Illinois yearly,
or agent thereof.
Non-resident dealer who is a manufacturer of 500,000 gallons or more per year combined plant total, FEE: $1,500.00
or agent thereof AND/OR primary U.S. importer exporting 500,000 gallons or more into Illinois yearly,
or agent thereof.
Illinois Liquor Control
Commission
JB Pritzker
Governor
100 W. RANDOLPH ST., SUITE 7-801
CHICAGO, ILLINOIS 60601
TELEPHONE: 312 814-2206
300 W. JEFFERSON ST., SUITE 300
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217 782-2136
All new applicants can email completed applications and attachments to
LCC.Licensing@illinois.gov
WEBSITE: ILCC.lllinois.gov
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
DATE ISSUED
EXPIRATION DATE
LICENSE NO.
Application for State of Illinois Non-resident Dealer’s Liquor License
IL 567-0059-A (1/2019)
PAGE 2 OF 4
CORPORATE/BUSINESS (DBA) INFORMATION
A.
3.
CORORATE 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.
Enter your Federal Employer Identication Number (FEIN) in this box. The FEIN is a nine-digit
number issued by the Internal Revenue Service. This number is used for verication purposes
only. If you do not have a FEIN, call 1 800 829-3676 for information on how to apply for and
obtain the forms you need. NOTE: The ILCC will accept your application as long as you have
led an application for your FEIN.
1.
FEIN
4.
CHIEF OPERATING ADDRESS/MAILING ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
2.
TELEPHONE
Enter the area code, telephone number and extension
of the sole proprietorship, corporation, etc.
AREA CODE/TELEPHONE NO.
( )
EXT.
FEIN #
DOING BUSINESS AS (DBA)
NAME
5,
CONTACT INFORMATION
Provide the contact information for your business. The contact person should be the responsible party we can contact and who can answer
questions on behalf of the business. The mobile or alternate number should be in addition to any business numbers on le. The email address
should be the active email address for the business, not the personal email address of the contact person.
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
• Effective September 1, 2020 all new applicants will have the option to
email their new liquor license applications and supporting documents to
LCC.Licensing@illinois.gov for review and processing.
• License fee payments shall be made by check through the mail within 3-7
business days to the Illinois Liquor Control Commission 100 W Randolph
Suite 7-801, Chicago, IL 60601 or 300 W Jefferson Suite 300,
Springfield, IL 62702.
F1 - Enter the street address, city, state, and ZIP code of the business. This must match the Federal Basic Permit or Brewers' Notice.
F2
- Enter the mailing address, including street address, city, state, and ZIP code, if different from the Business Address on Line F1.
F1
F2
IL 567-0059-A (1/2019)
PAGE 3 OF 4
APPLICANT INFORMATION
B.
Applicant is the:
6.
Actual manufacturer of the products described herein.
Primary U.S. importer of products described herein which are manufactured outside of the United States.
Provide an appointment letter from the manufacturer.
Duly registered agent of the manufacturer or duly registered agent of the primary U.S. importer of products described herein.
Provide an appointment letter from the manufacturer.
7. (a) List alphabetically, on separate sheet and attach, all of the alcoholic beverage products for distribution in Illinois, which you
manufacture, by their full product name as shown on their federally (BATF) approved labels.
(b) If you are not the actual manufacturer of any given alcoholic beverage product(s) which you distribute for sale within Illinois,
list alphabetically, by manufacturer on separate sheet, all of the alcoholic beverage products which you distribute as the
primary U.S. importer or duly registered agent.
NOTE: THE ANSWERS TO QUESTIONS 7(a) AND 7(b) DO NOT FULFILL THE SEPARATE REGISTRATION REQUIREMENTS SET FORTH
IN SECTION 5/6-9 OF THE ACT AND SECTION 100.60 OF THE RULES OF THE COMMISSION. THE SAME ARE TO BE REPORTED ON
THE REGISTRATION FORM OF THIS COMMISSION. PRODUCTS NOT SO REGISTERED MAY NOT BE DISTRIBUTED IN ILLINOIS EVEN
IF A NON-RESIDENT DEALER’S LICENSE IS SECURED. CHANGES IN PRODUCTS LISTED ON THIS FORM AND ON THE
REGISTRATION FORM MUST BE MADE PRIOR TO SHIPMENT OF PRODUCTS INTO ILLINOIS.
8. Have all Registration Statements required by Section 5/6-9 of the Act and Section 100.60 of the Rules of the Commission been
led by the person who owns or controls the brands listed above? Yes No
9. Has a pre-approved copy of the “BATF Application for Label Approval” been led for each and every product listed in your answer
to Question #7 and on your Registration Statement(s)? Yes No
10. List the name(s) and address(es) of all Illinois distributors who are currently registered under Section 5/6-9 to distribute these
products. (Attach a separate sheet if needed)
Is the applicant currently licensed in any capacity, other than a non-resident dealer, by this Commission?
Yes No If yes, give name of licensee and current state liquor license number.
Is any subsidiary, afliate, ofcer, associate, member, partner, representative, employee, agent, shareholder of the applicant, OR
the manufacturer for whom you act as primary United States importer or agent, OR is the manufacturer itself currently licensed in
any capacity, other than a non-resident dealer, by this Commission? Yes No
If yes, give name(s) of licensee(s) and current state liquor license number(s). (Attach additional sheet(s), if necessary)
12.
11.
ADDRESS OF ILLINOIS DISTRIBUTOR
NAME OF ILLINOIS DISTRIBUTOR
CURRENT ILLINOIS LIQUOR LICENSE NUMBER
NAME
CURRENT ILLINOIS LIQUOR LICENSE NUMBER
NAME
IL 567-0059-A (1/2019)
PAGE 4 OF 4
B.
APPLICANT INFORMATION (Cont’d)
If applicant warehouses liquor in Illinois, provide the street address, city, state, ZIP code and county of the warehouse.
ADDRESS
CITY
STATE
ZIP CODE
COUNTY
13.
14.
Name, title and phone number of person completing this application.
NAME
AREA CODE/PHONE NUMBER (Home, cell, etc.)
( )
TITLE
C.
OWNERSHIP INFORMATION
d.
Total percentage of all stock held by all persons with less than ve percent interest.
%
a.
b.
c.
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION AREA CODE/HOME TELEPHONE NO.
% OWNED
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION
% OWNED
( )
NAME (LAST, FIRST, MIDDLE INITIAL)
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NO.
DATE OF BIRTH
SEX TITLE/POSITION
% OWNED
For each owner/ofcer/partner/ve percent shareholder, provide full name, home address, city, state, ZIP code, Social Security number, date of birth,
sex, title/position, home telephone number, and ownership percentage. Total ownership percentage should equal 100 percent. If there are a number
of shareholders owning less than ve percent, indicate the aggregate total of ownership under Line d.
AREA CODE/HOME TELEPHONE NO.
AREA CODE/HOME TELEPHONE NO.
AFFIDAVIT
The above information is supplied for the purpose of inducing the Illinois Liquor Control Commission to issue a Non-resident
Dealer’s License to the applicant herein, and is true and correct, and made upon my personal knowledge and information. I further
swear or afrm that 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.
Signature of Applicant or Authorized Agent
Title or Position
Date
Signature of Applicant or Authorized Agent
Title or Position
Date
NOTE: If the license is to be issued to a partnership, two partners must sign. If the license is to be issued to a corporation, the president and
secretary of the corporation must sign, or duly authorized corporate representative.
IL 567-0014 (11/2016)
Registration Statement
(Illinois Compiled Statutes, Chapter 235)
TO THE ILLINOIS LIQUOR CONTROL COMMISSION:
Pursuant to the requirement of Section 6-9 of the Illinois Liquor Control Act of 1934, 235 ILCS 5/1-1, et.seq., 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 trademarks, 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 respective
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
TRADEMARK BRAND, OR
NAME OF ITEM
GEOGRAPHICAL
TERRITORY
TIME
PERIOD
CORPORATE NAME:
ADDRESS:
SIGNED BY:
DATE:
STATE LICENSE #
EXP. DATE
(Street Number)
(City or Town)
(Title)
This state agency is requesting disclosure of information
that is necessary to accomplish the statutory purpose
as outlined under the Illinois Liquor Control Act of
1934, 235 ILSC 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.
IMPORTANT NOTICE
SIGNATURE:
(Authorized Person)
IL 567-0053 (1/2019)
Illinois Liquor Control
Commission
JB Pritzker
Governor
APPLICATION FOR REGISTRATION
MANUFACTURER’S REGISTERED AGENT
100 W. RANDOLPH ST., SUITE 7-801
CHICAGO, ILLINOIS 60601
TELEPHONE: 312 814-2206
TDD: 312 814-1844
101 W. JEFFERSON ST., SUITE 3-525
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217 782-2136
WEBSITE: ILCC.llinois.gov
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
BUSINESS STREET ADDRESS
CITY
STATE
ZIP CODE
APPLICANT’S NAME Business, Partnership, Corporation)
TYPE OR PRINT INFORMATION
CURRENT LIQUOR LICENSE NO.
APPLICATION DATE
DOING BUSINESS AS (DBA)
BUSINESS TELEPHONE NUMBER
( )
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
MANUFACTURER’S AGENTS
Please list the name, address, phone number and email address of manufacturer’s agent(s) for which identication cards are requested.
For each individual listed, the applicant must attach a statement of representation. Attach additional sheets if necessary.
CONTACT INFORMATION
Provide the contact information for your business. The contact person should be the responsible party we can contact and who can answer questions on
behalf of the business. The mobile or alternate number should be in addition to any business numbers on le. The email address should be the active email
address for the business, not the personal email address of the contact person.
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
PAGE 1 OF 2
Does the applicant or associate hold any retail alcohol beverage license or any nancial or other interest in such a license
or establishment? If yes, describe and provide current license number: __________________________________
YES
NO
Has the applicant, partners or ofcers ever been convicted of any violation of the Illinois Liquor Control Act of a felony in
this state, any other state, or under federal liquor laws? If yes, please give full details.
YES
NO
PRINT FULL NAME AND TITLE OF APPLICANT
SIGNATURE OF APPLICANT
DATE
NOTE: Identication cards must be obtained for each sales representative employed. Cards expire concurrent with the manufacturer’s liquor license.
IL 567-0053 (1/2019) PAGE 2 OF 2
Illinois Liquor Control
Commission
JB Pritzker
Governor
STATEMENT OF REPRESENTATION
REGISTRATION OF MANUFACTURER’S AGENT
100 W. RANDOLPH ST., SUITE 7-801
CHICAGO, ILLINOIS 60601
TELEPHONE: 312 814-2206
TDD: 312 814-1844
101 W. JEFFERSON ST., SUITE 3-525
SPRINGFIELD, ILLINOIS 62702
TELEPHONE: 217 782-2136
WEBSITE: ILCC.llinois.gov
I, ______________________________________________ as ___________________________________________________
for _________________________________________________________________________________ have a contractual agreement
with ________________________________________________________________________________ to represent and promote our
products. This agreement covers the following territories:
I understand that under Illinois law:
Registration of agents, representatives, or persons acting on behalf of a manufacturer is fullled by submitting a form to the
Commission. The form shall be developed by the Commission and shall include the name and address of the applicant,
the name and address of the manufacturer he or she represents, the territory or areas assigned to sell to or discuss pricing
terms of alcoholic liquor, and any other questions deemed appropriate and necessary. All statements in the forms required
to be made by law or by rule shall be deemed material, and any person who knowingly misstates any material fact
under oath in an application is guilty of a Class B misdemeanor. Fraud, misrepresentation, false statements, misleading
statements, evasions, or suppression of material facts in the securing of a registration are grounds for suspension or
revocation of the registration. (235 ILCS 5/5-1)
SIGNATURE OF MANUFACTURER
TITLE
DATE
NOTE: Identification cards must be obtained for each sales representative employed. Cards expire concurrent with the manufacturer’s liquor license.
IL 567-0053 (1/2019)
NAME TITLE
NAME OF MANUFACTURER
NAME OF MANUFACTURER’S AGENT
SIGNATURE OF MANUFACTURER’S AGENT
SOCIAL SECURITY NUMBER
DATE
DATE OF BIRTH
CONTACT INFORMATION
Provide the contact information for your business. The contact person should be the responsible party we can contact and who can answer questions on
behalf of the business. The mobile or alternate number should be in addition to any business numbers on le. The email address should be the active email
address for the business, not the personal email address of the contact person.
CONTACT PERSON’S NAME (First, Last)
BUSINESS PHONE NUMBER
( )
ALTERNATE PHONE NUMBER (Home, Cell, etc.)
EMAIL ADDRESS
FAX NUMBER
( )
( )
Illinois Department of Revenue
RL-26-L Schedule L
Out-of-state Sellers’ Shipment Report
Read this information fi rst
Make a copy of this schedule before completion if you need to report more than provided for here. After you have
completed your schedule(s), make a photocopy and retain the copy for your records.
Step 1: Identify your business
a Name:_______________________________________________ Account ID:
__ __ __ __ __ __ __ __
Address:_____________________________________________ License number: LM - ___ ___ ___ ___ ___
Number and street
_____________________________________________________ FEIN: ___ ___ - ___ ___ ___ ___ ___ ___ ___
City State/Province ZIP Federal Employer Identifi cation number
Country/Territory:___________________________ Liability period: __ __/__ __ __ __ (Month/Year)
b Check here if you had no shipments to report during this tax period. Telephone: (_____)______- ___________ Ext:_________
Step 2: Tell us about the alcoholic liquors you shipped into Illinois
Equivalent in wine gallons
Invoice no. FEIN of Name and complete address of
Cider 0.5 % Alcohol 14 % Alcohol > 14% Alcohol 20%
and date whom you sold and whom you sold and shipped to
to 7% or beer or less and < 20% or more
shipped to
____________ ___________ ______________________________________________ __________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ______________________________________________ __________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ______________________________________________ __________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ______________________________________________ __________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ______________________________________________ __________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
____________ ___________ ______________________________________________ __________ __________ __________ __________
_ _/_ _/_ _ _ _ ______________________________________________
______________________________________________
Page subtotal _________ __________ _________ _________
Grand total _________ __________ _________ _________
RL-26-L (R-04/12)
IL-492-1493
*035611110*
Page ____ of ____
RL-26-L (R-04/12)
Schedule L Instructions
General Information
Who must fi le this schedule?
You must fi le Schedule L, Out-of-state Sellers’ Shipment
Report, if you are a seller located outside of Illinois and make
shipments of alcoholic liquors into Illinois.
When and where do I fi le Schedule L?
You must fi le Schedule L on or before the fi fteenth day of each
month for the preceding month.
Note: You must fi le Schedule L even if you made no ship-
ments during the reporting period.
Mail your completed schedule to
ALCOHOL, TOBACCO AND FUEL DIVISION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19477
SPRINGFIELD IL 62794-9477
Note: If you prefer, you can fi le Form RL-26-L using our Web-
File program at tax.illinois.gov.
What if I need assistance?
If you have questions about Schedule L, call us weekdays
from 8:00 a.m. to 4:30 p.m. at 217 782-6045 or write to us at
the address listed above.
Step-by-Step Instructions
Step 1: Identify your business and type of
transaction
a Write your business’ name, address, License number,
(issued by us) and Account ID. Also, tell us your Federal
Employer Identifi cation number (FEIN) and the liability
period for which you are fi ling this schedule.
b Check here if you had no shipments to report during this
reporting period.
Step 2: Tell us about the alcoholic liquors you
shipped into Illinois
You must provide the invoice number (include the invoice
date) and purchasers’ FEIN number.
Tell us the name and address of whom you sold or shipped
the alcoholic liquors you are reporting.
Report the total actual wine gallonage equivalent for each
class of alcoholic liquor per invoice number.
Grand total:
If you are fi ling only one page, copy the “Page subtotal”
amounts to the “Grand total” lines.
If you are fi ling multiple pages, add all “Page subtotals”
together for each liquor class and write each sum on the
appropriate “Grand total” line on the last page.
This form is authorized by the Liquor Control Act of 1934. Disclosure of this information is REQUIRED. Failure to provide
information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-1493
*ZZZZZZZZZ*
Print
REG-1 (R-12/19)
Illinois Department of Revenue
REG-1 Illinois Business Registration Application
Register faster using MyTax Illinois, our online account management program, available at mytax.illinois.gov. If you have questions, visit our
website at tax.illinois.gov or call us weekdays between 8:00 a.m. and 4:30 p.m. at 217 785-3707.
Step 1: Identify your business or organization
1 Federal employer identification number (FEIN)
FEIN: ______ - __________________
Proprietorships must provide the Social Security number (SSN)
under which taxes will be filed.
SSN: _________ - ______ - ____________
2 Legal business name:
___________________________________________________
3 Doing-business-as (DBA), assumed, or trade name, if different
from Line 2:
___________________________________________________
4 Primary or legal business address:
___________________________________________________
Street address - No PO Box number Apartment or suite number
___________________________________________________
City State ZIP
If you have other locations in Illinois from where you do
business, complete and attach Schedule REG-1-L.
5 Mailing address if different from the address above:
___________________________________________________
In-care-of name
___________________________________________________
Street address or PO Box number Apartment or suite number
___________________________________________________
City State ZIP
6 Check the organization type that applies to you:
q Proprietorship
____ Check if owned by a married couple or civil union
q Partnership q Trust or estate
q Corporation* q
S Corp (Subchapter S Corporation)
*
*
Is your corporation publicly traded? ___ Yes ___ No
If yes, provide the ticker symbol ____________
q Governmental unit q Not-for-profit organization
q LLC - Corporation q LLC - Partnership
q LLC - S Corporation q LLC - Single member
____ Check if your organization type is disregarded
7 Illinois Secretary of State identification number:
___ - ___ ___ ___ ___ - ___ ___ ___ - ___
8 Is your business part of a unitary group? ___ Yes ___ No
If “Yes”, provide the FEIN of your designated agent (the entity
responsible for filing your Illinois income tax return):
FEIN: ______ - __________________
9 Identify a contact person regarding your business.
Name: __________________________ Title:
_____________
Phone: (______) ______ - ________ Ext.: __________
FAX: (______) ______ - ________
Email address:
______________________________________
Step 2: Identify your owners and officers - If you need to identify more, attach Schedule REG-1-O.
10
Identification depends on the organization type you selected in Step 1, Line 6 (proprietorship - owner(s); partnership - general partners; non-publicly traded
corporation - president, secretary, and treasurer; publicly traded corporation - chief operating officer and chief financial
officer; trust or estate - trustee(s) or
executor(s); governmental unit - one contact person; not-for-profit organization - president, secretary, or
treasurer; limited liability company - managers and
members). For each individual or business required, complete the following information.
Individuals: (include Social Security number (SSN))
a ___________________________________
_________________
Name Title
______________________________________________________
Home address - No PO Box number City State ZIP
____ / ____ / ________ (______) ______ - ________
Date of birth Phone
_______ - _____ - _________ Ownership percentage: ______
Social Security number
b ___________________________________
_________________
Name Title
______________________________________________________
Home address - No PO Box number City State ZIP
____ / ____ / ________ (______) ______ - ________
Date of birth Phone
_______ - _____ - _________ Ownership percentage: ______
Social Security number
c ___________________________________
_________________
Name Title
______________________________________________________
Home address - No PO Box number City State ZIP
____ / ____ / ________ (______) ______ - ________
Date of birth Phone
_______ - _____ - _________ Ownership percentage: ______
Social Security number
d ___________________________________
_________________
Name Title
______________________________________________________
Home address - No PO Box number City State ZIP
____ / ____ / ________ (______) ______ - ________
Date of birth Phone
_______ - _____ - _________ Ownership percentage: ______
Social Security number
Businesses: (include federal employer identification number (FEIN))
a ___________________________________ ____-_____________
Name FEIN
______________________________________________________
Legal address
______________________________________________________
City State ZIP
(______) ______ - ________ Ownership percentage: ______
Phone
b ___________________________________ ____-_____________
Name FEIN
______________________________________________________
Legal address
______________________________________________________
City State ZIP
(______) ______ - ________ Ownership percentage: ______
Phone
*74512191W*
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
REG-1 (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
Mail your completed form, with any required
attachments and payment to:
CENTRAL REGISTRATION DIVISION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19030
SPRINGFIELD IL 62794-9030
Step 4: 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:
q
Signature: _______________________________________ Title:
________________________
Date: ___/___/______
Printed name: _______________________________________ SSN:
______
- _____ - _________
Address: _______________________________________ Phone: (______) ______
-
_________
*74512192W*
Step 3: Tell us about your business activities
11 Describe your business activities: ______________________
____________________________________________
Provide your North American Industry Classification System
(NAICS) number: ___________________________________
Refer to the website www.naics.com
12 Will you have Illinois employees? ____ Yes ____ No
If yes, complete and attach Schedule REG-UI-1.
When was (is) the date of your first payroll in Illinois?
____/____/_____
13 Check all that apply to your type of business.
Sales and Use Tax
You must complete and attach Schedule REG-1-L to identify
all Illinois locations from which you make retail sales.
q General merchandise: ____ Retail ____ Wholesale
Do you estimate your monthly sales and use tax liability will
be over $200? ____ Yes ____ No
q Sales to Illinois customers from out of state
____ Check if you have an Illinois presence,
including, but not limited to having an office
or other facility in Illinois or having employees or
other representatives operating in Illinois.
____ Check if you make $100,000 or more in annual
sales from your own sales to Illinois purchasers.
____ Check if you make 200 or more separate
transactions annually from your own sales to
Illinois purchasers.
q Check if you are a marketplace facilitator - Attach
Schedule REG-1-MKP.
q Soft drinks (other than fountain soft drinks) in Chicago
q Vehicle, watercraft, aircraft, or trailers
q Sales or delivery of tires. Do you always pay the
Tire User Fee to your supplier? ____ Yes ____ No
q Sales from vending machines. How many vending
machines? ______
q Liquor at retail (bar, tavern, liquor store, etc.)
q Motor fuel/fuel: ____ Retail ____ Wholesale
____ Check here if you are required to collect prepaid
sales tax.
q Medical cannabis - Attach Schedule REG-1-MC.
____ Cultivation Center ____ Dispensing Organization
qAviation fuel: ____ Retail ____ Wholesale
(if wholesale, attach Schedule REG-8-A)
When will (did) these activities begin? ____/____/_____
Services
Do you transfer items, on which tax must be collected, as part of
your service?
____ Yes ____ No
When will (did) this activity begin? ____/____/_____
Purchaser (Self-assessed Use Tax)
Does your supplier collect Illinois Sales Tax for merchandise your
business uses or consumes in Illinois?
____ Yes ____ No
Does your supplier collect Illinois Sales Tax on sales of aviation
fuel your business uses or consumes in Illinois?
____ Yes ____ No
When will (did) these activities begin? ____/____/_____
Cigarettes and other tobacco products
q Cigarettes - See Schedule REG-1-C before you check here.
q Tobacco products - See Schedule REG-1-C before you check
here.
q Cigarette machine operator - See Schedule REG-1-C before
you check here.
When will (did) these activities begin? ____/____/_____
Renting or leasing
q
Hotel rooms for less than 30 days - Attach Schedule REG-1-L
.
Do you charge for telecommunication services?
____ Yes ____ No
q Vehicles for one year or less - Attach Schedule REG-1-L.
q Vehicles for more than one year
When will (did) these activities begin? ____/____/_____
Utility providers
q Electricity: ____ Retail ____ Wholesale
q Natural gas: ____ Retail ____ Wholesale
q Telecommunications - See Schedule REG-1-T.
____ Retail ____ Wholesale
q Water or sewer services
Are you a utility cooperative? ____ Yes ____ No
Are you a municipality? ____ Yes ____ No
When will (did) these activities begin? ____/____/_____
All other tax types
q Liquor warehousing - Attach Schedule REG-1-A.
q Dry cleaning: ____ Facility ____ Solvent supplier
q Own/operate coin-operated amusement devices
q You wish to purchase electricity for non-residential use and pay
the tax to IDOR - Attach Schedule REG-1-D.
q You wish to purchase natural gas from outside of
Illinois for your own use and pay the tax to IDOR - Attach
Schedule REG-1-G.
q Not listed. Identify: _________________________________
When will (did) these activities begin? ____/____/_____
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Illinois Liquor Control JB Pritzker Commission Governor WEBSITE: (Illinois)

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Completed 5 July 2021

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