Fillable Printable Schedule Reg-1-O, Owner And Officer Information
Fillable Printable Schedule Reg-1-O, Owner And Officer Information
Schedule Reg-1-O, Owner And Officer Information
Illinois Department of Revenue
Schedule REG-1-O Owner and Officer Information
Read this information first - If you are a first time registrant, attach this schedule to Form REG-1.
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 officer and chief financial officer
Trust or estate — each trustee or executor
Not-for-profit organization — the president, secretary, or treasurer
Limited liability company — each manager and member
Governmental unit — one contact person (for example, the liaison)
Step 1: Identify your business or organization
Business name: __
_____________________________________________
FEIN: ______ - __________________
If your business is a corporation, are you publicly traded? ___ Yes ___ No SSN: _________ - ______ - ____________
(Proprietorship only)
If “Yes”, provide the ticker symbol:
________________
Contact for this schedule: __
_______________________________
Phone: (______) ______ - _________
Step 2: Identify your owners and officers
1 Individuals - For each individual required, complete the following information (including the Social Security number).
a ____________________________________ _________________ c ____________________________________ _________________
Name Title Name Title
________________________________________________________ ________________________________________________________
Home address - No PO Box number City State ZIP Home address - No PO Box number City State ZIP
____ / ____ / ________ (______) ______ - ________ ____ / ____ / ________ (______) ______ - ________
Date of birth Phone Date of birth Phone
_______ - _____ - _________ Ownership percentage: _______ _______ - _____ - _________ Ownership percentage: _______
Social Security number Social Security number
b ____________________________________ _________________ d ____________________________________ _________________
Name Title Name Title
________________________________________________________ ________________________________________________________
Home address - No PO Box number City State ZIP Home address - No PO Box number City State ZIP
____ / ____ / ________ (______) ______ - ________ ____ / ____ / ________ (______) ______ - ________
Date of birth Phone Date of birth Phone
_______ - _____ - _________ 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 identification number (FEIN)).
a ____________________________________ ____-
_____________
b ____________________________________ ____-
_____________
Name FEIN Name FEIN
________________________________________________________ ________________________________________________________
Legal address Legal address
________________________________________________________ ________________________________________________________
City State ZIP City State ZIP
(______) ______ - ________ Ownership percentage: _______ (______) ______ - ________ Ownership percentage: _______
Phone Phone
Step 3: Remove owners and officers (for current registrants only, not new registrants)
Complete the following information (including the Social Security number) if you need to remove an owner or officer from our registration records.
a ____________________________________ _________________ b ____________________________________ _________________
Name Title Name Title
____ / ____ / ________ (______) ______ - ________ ____ / ____ / ________ (______) ______ - ________
Date of birth Phone Date of birth Phone
_______ - _____ - _________ ____ / ____ / ________ _______ - _____ - _________ ____ / ____ / ________
Social Security number Date ceased as owner/officer Social Security number Date ceased as owner/officer
Step 4: Sign here
Under penalties of perjury, I certify I have examined all the information provided for my registration or renewal application and, to the best of my
knowledge, it is true, correct, and complete.
Signature:_____________________________________________________ Date: ___/___/_______
Printed name: _______________________________________________ Title: ___________________________
Fax your completed schedule to 217 785-6013 or mail to:
CENTRAL REGISTRATION DIVISION 3-222
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19030
SPRINGFIELD IL 62794-9030
Schedule REG-1-O (R-04/16)
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.
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