Fillable Printable Rb-2, Application For Bingo Supplier
Fillable Printable Rb-2, Application For Bingo Supplier
Rb-2, Application For Bingo Supplier
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
____ / ____ / ________ (______) ______ - ________
Phone Date of birth
_______ - _____ - _________ 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 ___________________________________
_________________
Title Name
______________________________________________________
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
RB-2 front (R-06/15)
Step 1: Identify your business or organization
1 Federal employer identification number (FEIN)
______ - __________________
FEIN:
under which taxes will be filed.
Proprietorships must provide the Social Security number (SSN)
_________ - ______ - ____________
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 Apartment or suite number PO Box number
___________________________________________________
State City ZIP
5 Mailing address if different from the address above:
___________________________________________________
In-care-of name
___________________________________________________
Street address or PO Box number Apartment or suite number
___________________________________________________
State City ZIP
6 Check the organization type that applies to you:
Proprietorship
____ Check if owned by a married couple or civil union
Partnership Trust or estate
* *
Corporation
S Corp (Subchapter S Corporation)
*
Is your corporation publicly traded? ___ Yes ___ No
____________
If yes, provide the ticker symbol
Governmental unit Not-for-profit organization
LLC - Corporation LLC - Partnership
LLC - Single member
____ Check if 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.
__________________________ Title:Name:
_____________
______) ______ - ________ Ext.: __________
Phone: (
______) ______ - ________
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.
Illinois Department of Revenue
RB-2
Register faster using MyTax Illinois, our online account management program, available on our website at tax.illinois.gov. If you have
questions, visit our website or contact us weekdays between 8:00 a.m. and 4:30 p.m. at 217 785-5864 or email at rev[email protected].
Application for Bingo Supplier’s License
Use your 'Mouse' or the 'Tab key' to move through the fields and 'Mouse' or 'Space bar' to enable the checkboxes.
0%
0%
0%
0%
0%
0%
Step 3: List all locations where your equipment is stored - Attach additional sheets if necessary
a
_________________________________________________ d __________________________________________________
Street address - No PO Box number Apartment or suite number Street address - No PO Box number Apartment or suite number
______________________________________________________
_______________________________________________________
City State ZIP City State ZIP
b _________________________________________________ e __________________________________________________
Street address - No PO Box number Apartment or suite number Street address - No PO Box number Apartment or suite number
______________________________________________________ ________________________________________________________
City State ZIP City State ZIP
c
_________________________________________________ f ___________________________________________________
Street address - No PO Box number Apartment or suite number Street address - No PO Box number Apartment or suite number
______________________________________________________
_______________________________________________________
City State ZIP City State ZIP
Step 4:
Type of license you are applying for - Check one -
(
Note: The fee paid with your application is not refundable.)
If you are applying for a
One year bingo supplier license, the fee is $200.
Three year bingo supplier license, the fee is $600.
Make your check or money order payable to the “Illinois Department of Revenue.”
Step 5: Sign below
Under the penalties of perjury, I state that I have examined this application and all attachments and other information required and to the best
of my knowledge, it is true, correct, and complete.
________________________________________________________________________________________________________________
Signature Printed name Date
OFFICE OF BINGO AND CHARITABLE GAMES 3-215
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19480
SPRINGFIELD IL 62794-9480
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.
RB-2 back (R-06/15)
Mail your completed form along with any
attachments and payment to:
Reset
Print
