Lobbyist Change of Authorized Agent Attachment
Secretary of State Index Department
111 E. Monroe
Springfield, IL 62756
217-782-7017
217-557-8919 (fax)
www.cyberdriveillinois.com
eLobbyist@ilsos.gov
Entity Number: _____________________________________________________________________
Entity Name:_________________________________________________________________________
Authorized Agent’s System PIN: ________________________________________________________
Type of change you are submitting:
q Designating a new authorized agent
(Complete sections I, III, IV)
q Change in name (due to marriage, etc.) of current authorized agent
(Complete sections II, IV)
Section I:
I,
_____________________________________________________________________
, the undersigned have assumed the duties of
Please print name
authorized agent effective
_____________________________________
for the above named entity.
Date
Section II:
Current name of authorized agent:
__________________________________________________________________________________
Former name of authorized agent:
__________________________________________________________________________________
Section III:
Address to which all correspondence should be mailed:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Phone:
_________________________________________________
Fax:
__________________________________________________
Email: __________________________________________________________________________________________________________
Section IV:
________________________________________________________ _________________________________________
Signature Date
Printed by authority of the State of Illinois - July 2020 - 1 - I-197.3
A new authorized agent must set up and establish a user name, password and PIN on the Lobbyist
Registration System prior to submitting this form.
