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Illinois Department of Revenue
REG-3-D Request for Signature
Read this information first
Form REG-3-D must be filled out in its entirety to complete your registration or to change information previously provided for a registered
business. Signature stamps are not acceptable. You can fax Form REG-3-D to us at 217 785-6013. If you prefer, mail your completed
Form REG-3-D to the Central Registration Division, Illinois Department of Revenue, PO Box 19030, Springfield Illinois 62794-9030.
Step 1: Provide your business or organization information
Internet applicants must provide the application code. If you are changing information for a previously registered business, tell
us your Illinois Business Tax number (IBT no.).
____________________________________________________________ (_____)_____ - ______________
Name of your business Daytime telephone
____________________________________________________________ ________-________-________-______
Street address of your business Application code (e.g., A999-A999-A999-9999)
____________________________________________________________ ___ ___ ___ ___ - ___ ___ ___ ___
City State ZIP Illinois Business Tax number (IBT no.)
Step 2: 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: ___________________________
Address: ___________________________________________________________________________________________
Step 3: Tell us the person(s) responsible for filing returns and paying taxes and fees due
The tax responsibilities listed below require the person who will be responsible for filing tax returns and paying the tax or fee due to
complete the following information and sign. If you need to identify more, attach additional sheets using a similar format.
____________________________________________________________ (_____)_____ - ______________
Name Daytime telephone
____________________________________________________________ ___ ___ ___-___ ___-___ ___ ___ ___
Address Social Security number (SSN)
Check all tax types for which you are responsible for filing returns and paying the tax or fee due.
___ Withholding Income Tax ___ Sales, Service & Use Taxes
___ Motor Vehicle Renting Tax ___ Hotel Operators' Tax
___ Motor Fuel Tax ___ Environmental Impact Fee & Underground Storage Tax
Under penalties of perjury, I state that I am personally responsible for filing and paying the taxes and fees listed above.
______________________________________________ ____/____/______
Signature Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
____________________________________________________________ (_____)_____ - ______________
Name Daytime telephone
____________________________________________________________ ___ ___ ___-___ ___-___ ___ ___ ___
Address Social Security number (SSN)
Check all tax types for which you are responsible for filing returns and paying the tax or fee due.
___ Withholding Income Tax ___ Sales, Service & Use Taxes
___ Motor Vehicle Renting Tax ___ Hotel Operators' Tax
___ Motor Fuel Tax ___ Environmental Impact Fee & Underground Storage Tax
Under penalties of perjury, I state that I am personally responsible for filing and paying the taxes and fees listed above.
______________________________________________ ____/____/______
Signature Date
This form is authorized by 20 ILCS 687/6-1 et seq.; 35 ILCS 5/1 et seq., 105/1 et seq., 110/1 et seq., 115/1 et seq., 120/1 et seq., 130/1 et seq., 135/1 et seq., 143/10-1 et seq., 145 et seq., 155/1 et seq., 173/5-1 et
seq., 505/1 et seq., 510/1 et seq., 615/1/et seq., 620/1 et seq., 625/1 et seq., 630/1 et seq.; 35 ILCS 635/1 et seq., 636/5-1 et seq., 640/2-1 et seq.; 230 ILCS 20/1 et seq., 25/1 et seq., 30/1 et seq.; 235 ILCS 5/1-1
et seq.; 305 ILCS 20/5 et seq.; 415 ILCS 125/301 et seq. Disclosure of this information may be REQUIRED. Failure to provide information could result in this form not being processed and possible penalties. This
form has been approved by the Forms Management Center. IL-492-0001
REG-3-D (R-06/04)
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