llinois Department of Revenue - PDF document

1 Reset Reset Print Print I llinois Depa
Reset Reset Print Print I llinois Department of Revenue Schedule REG-8-O Owner and Ofcer Information Read this information rst - Attach this schedule to Form REG-8-A. If your organization is a: then complete Step 2 to identify: Proprietorship — the owner (if husband/wife or civil union, enter both individuals’ information) Partnership — each general partner Corporation or S Corp* — the president, secretary, and treasurer *If publicly traded (identify below) — the chief operating ofcer and chief nancial ofcer Trust or estate — each trustee or executor Not-for-prot organization — the president, secretary, or treasurer Governmental unit — one contact person (for example, the liaison) Identify your business or organization Business name: __ _____________________________________________ If your business is a corporation, are you publicly traded? Yes No (Proprietorship only) If “Yes”, provide the ticker symbol: ________________ Contact for this schedule: __ _______________________________ Phone: (______) ______ - _________ Identify your owners and ofcers 1 Individuals - For each individual required , complete the following information (including the Social Security number ). a _ ___________________________________ _________________ c _ ___________________________________ _________________ Title No PO Box number City State ZIP No PO Box number City State ZIP Ownership percentage: _______ - _____ - _________ Ownership percentage: _______ Social Security number Social Security number b _ ___________________________________ _________________ d _ ___________________________________ _________________ Title No PO Box number City State ZIP No PO Box number City State ZIP Date of birth Date of birth Ownership percentage: _______ - _____ - _________ Ownership percentage: _______ Social Security number Social Security number 2 Businesses - For each business that is an owner, complete the following information (including the Federal Employer Identication Number ( FEIN )). a _ ___________________________________ ____- _____________ b _ ___________________________________ ____- _____________ ________________________________________________________ ________________________________________________________ Ownership percentage: (______) ______ - ________ Ownership percentage: _______ Remove owners and ofcers (for current registrants only, not new registrants) Complete the following information (including the Social Security number ) if you need to remove an owner or ofcer from our registration records. a _ ___________________________________ _________________ b _ ___________________________________ _________________ Title Date of birth Date of birth _______ - _____ - _____________ / ____ / ________ Social Security numberDate ceased as owner/ofcerSocial Security numberDate ceased as owner/ofcer Step 4: Sign here 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. Date: ___/___/_______ Mail your completed schedule to: ALCOHOL, TOBACCO, AND FUEL DIVISION ILLINOIS DEPARTMENT OF REVENUE PO BOX 19467 Schedule REG-8-O (N-12/17) This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is led. 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).