Form CFT23 Schedule G "Schedule for First-Year Irp Applicants or Business Operational Changes" - Illinois

What Is Form CFT23 Schedule G?

This is a legal form that was released by the Illinois Secretary of State - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Illinois Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFT23 Schedule G by clicking the link below or browse more documents and templates provided by the Illinois Secretary of State.

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Download Form CFT23 Schedule G "Schedule for First-Year Irp Applicants or Business Operational Changes" - Illinois

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This space for use by
Secretary of State
Secretary of State.
“Schedule G” for First-Year IRP Applicants or
Business Operational Changes
Secretary of State
Distance records on which this application is
Vehicle Services Department
based must be retained for a period of three years
Commercial & Farm Truck Division
after the expiration of each registration year
501 S. Second St., Rm. 300
(total of five years and nine months). Retention
Springfield, IL 62756
of records is very important to avoid excessive
217-785-1800
penalties that may arise during audit examination.
www.cyberdriveillinois.com
Name: _________________________________________________________
FEIN: ___________________________
Address: _______________________________________ City/State/ZIP: _____________________________________
Telephone #: ____________________________________ Additional Telephone #: _____________________________
Prior to the issuance of your registration, the Office of the Secretary of State, pursuant to 625 ILCS, Sections 5/2-
110 and 5/3-405, requires the following questions to be completed in full. For any question requiring additional
information, additional sheets may be attached. Information provided may require further verification. The Office
of the Secretary of State reserves the right to request documentation for substantiation and verification. For cur-
rent IRP firms, please only complete questions regarding the part of your operations that has changed from the
previous filing.
Part I, Business Ownership Information
Please explain about your business ownership and those persons associated with the operations, if any.
n
1. Business Type -
Individual or Proprietorship (includes Owner/Operator)
n
Partnership
n
Company
n
Corporation – IL Corporation Number or State of Incorporation if foreign: ___________________
A copy of a “Certificate of Good Standing” is required for a foreign corporation.
n
Limited Liability Company (LLC) - IL LLC Number or State if foreign: _____________________
A copy of a “Certificate of Good Standing” is required for a foreign LLC.
n
Other – Describe _____________________________________________________________
2. Please list the Name, Address and Phone Number of any person (including yourself), officer, partner, spouse, family
member, trustee, or other entity (including other business names or corporations) that have more than a 10% ownership
stake in this business:
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
4. ________________________________________________________________________________________
5. ________________________________________________________________________________________
Please attach additional sheets, if necessary.
3. Have you, an immediate family member, or any of the above named parties had an IRP based in Illinois or any other
n
jurisdiction during the past three years?
…………………………………………………………………………n
YES
NO
If yes, give firm/account number(s) and jurisdiction(s):
_________________________________________________
Page 1
Printed by Authority of the State of Illinois. August 2020 — 1 — CFT 23.14
Print
Reset
This space for use by
Secretary of State
Secretary of State.
“Schedule G” for First-Year IRP Applicants or
Business Operational Changes
Secretary of State
Distance records on which this application is
Vehicle Services Department
based must be retained for a period of three years
Commercial & Farm Truck Division
after the expiration of each registration year
501 S. Second St., Rm. 300
(total of five years and nine months). Retention
Springfield, IL 62756
of records is very important to avoid excessive
217-785-1800
penalties that may arise during audit examination.
www.cyberdriveillinois.com
Name: _________________________________________________________
FEIN: ___________________________
Address: _______________________________________ City/State/ZIP: _____________________________________
Telephone #: ____________________________________ Additional Telephone #: _____________________________
Prior to the issuance of your registration, the Office of the Secretary of State, pursuant to 625 ILCS, Sections 5/2-
110 and 5/3-405, requires the following questions to be completed in full. For any question requiring additional
information, additional sheets may be attached. Information provided may require further verification. The Office
of the Secretary of State reserves the right to request documentation for substantiation and verification. For cur-
rent IRP firms, please only complete questions regarding the part of your operations that has changed from the
previous filing.
Part I, Business Ownership Information
Please explain about your business ownership and those persons associated with the operations, if any.
n
1. Business Type -
Individual or Proprietorship (includes Owner/Operator)
n
Partnership
n
Company
n
Corporation – IL Corporation Number or State of Incorporation if foreign: ___________________
A copy of a “Certificate of Good Standing” is required for a foreign corporation.
n
Limited Liability Company (LLC) - IL LLC Number or State if foreign: _____________________
A copy of a “Certificate of Good Standing” is required for a foreign LLC.
n
Other – Describe _____________________________________________________________
2. Please list the Name, Address and Phone Number of any person (including yourself), officer, partner, spouse, family
member, trustee, or other entity (including other business names or corporations) that have more than a 10% ownership
stake in this business:
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
4. ________________________________________________________________________________________
5. ________________________________________________________________________________________
Please attach additional sheets, if necessary.
3. Have you, an immediate family member, or any of the above named parties had an IRP based in Illinois or any other
n
jurisdiction during the past three years?
…………………………………………………………………………n
YES
NO
If yes, give firm/account number(s) and jurisdiction(s):
_________________________________________________
Page 1
Printed by Authority of the State of Illinois. August 2020 — 1 — CFT 23.14
n
n
4. Is the business address a personal residence? ……………………………………………………………….
YES
NO
If yes, what is the name and relationship to the registrant?: _______________________________________________
n
n
5. Will you keep your records for audit purposes at this address?……………………………………………….
YES
NO
If no, why not and at what address will the records be retained?: ___________________________________________
_______________________________________________________________________________________________
Part II, Vehicle Registration Information
1. Indicate how these vehicles were registered previously (includes those under your ownership and leased to another
company). If an existing registrant making changes in business operations, select A. If newly purchased, skip to E;
attach additional sheets if necessary. If vehicles were not registered, explain in F.
n
A.
Existing IRP Registrant – Business Operations Change Only - Firm #: ______________________________
n
B.
Illinois base plate - Name and Plate #: ________________________________________________________
n
C.
Illinois IRP plate - Name and Plate #: __________________________________________________________
n
D.
Foreign plate - (out of state) - State of Issuance: __________________________________________________
Foreign base plate - Name and Plate #: ____________________________________________________
Foreign IRP plate - Name and Plate #: ____________________________________________________
n
E.
New Purchase - (Vehicles recently purchased or not in your possession in the previous registration year.)
Purchased from: ______________________________________________________________________
Relationship to applicant (if any): ________________________________________________________
n
F.
Other - Explain in detail. ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Part III, USDOT and Authority Information
Please be specific on the requested information. If further explanation is necessary, please attach an additional sheet.
1. USDOT Number responsible for safety: __________________ FEIN of entity: _______________________________
Name(s) and Address(es) of carrier whose USDOT Number is responsible for Safety:
______________________________________________________________________________________________
If more than one USDOT number or carrier is responsible for the safety of your vehicle(s), please use an additional
sheet to list all.
USDOT Type Business:
n
n
n
n
n
Motor Carrier
Broker
Freight Forwarder
Hazardous Material Shipper
Cargo Tank Facility
Operating Authority Number you will be working under (if any) #: ___________________________________________
n
n
Jurisdiction of Issue: _______________________________ Is this your authority? ....…………………
YES
NO
If No, Name and Address of Authority Holder: __________________________________________________________
n
n
Could the USDOT Number for Safety change in the next 12 months? …………………………………...…
YES
NO
n
n
2. Has anyone listed in Part I, #2 ever had a USDOT Number of his/her own? ………………………………
YES
NO
If yes, give USDOT Number and explain: _____________________________________________________________
Please be advised that applications will not be processed and issued registration without proof that they are either
a Carrier or leased to a Carrier who has a valid USDOT Number for Safety Operations. You may be asked to provide
proof of that Carrier’s USDOT Number and FEIN to obtain registration.
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Part IV, Business Plan for Operations
1. Provide a detailed explanation of how you will obtain your loads, who you may obtain them from, and what you may
transport. (Registration may be denied if not adequately answered. Attach additional sheets if necessary.)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
n
2. Is there any actual distance that has been accrued by your vehicle(s) that will require to be reported?
...n
YES
NO
If yes, explain origin of distance: ____________________________________________________________________
n
n
3. Have you been instructed on the importance of maintaining individual vehicle distance records? ..……..
YES
NO
n
n
4. Have you read the distance recordkeeping requirements outlined in the IRP Instruction Manual? ...…….
YES
NO
5. I am aware that the origin, destination, route traveled and odometer readings must be included within the required
n
records to accurately account for distance traveled within a particular jurisdiction?
......................………n
YES
NO
Part V, Driver Information
Please explain who will be operating your vehicles.
n
n
1. Are you the driver of the vehicle(s)? ………………………………………………………………………..…….
YES
NO
n
n
If yes, Driver’s License #: __________________________ State of Issuance: _______________ CDL
YES
NO
n
Will you employ drivers other than yourself?
.................………………………………………………….…….n
YES
NO
n
n
2. Has any driver or potential driver listed had his/her license suspended or revoked? …….…………………
YES
NO
If yes, give Jurisdiction and explain: _________________________________________________________________
Part VI, General Information and Affirmation
1. Has any licensing service, remittance agency, trucking service agency, consultant or any other individual(s) assisted
n
you in the preparation of your IRP application(s)?
………………………………………………………………n
YES
NO
If yes, Name and Address: ________________________________________________________________________
Did the above named business/person advise you where to find the documents or provide you with the necessary
n
information/rules to comply with being an apportioned registrant?
..…………........................................…n
YES
NO
n
n
2. Do you owe any fees, fines, penalties, assessments or other unpaid billings to any jurisdiction? ………..
YES
NO
If yes, explain: __________________________________________________________________________________
I (we) hereby affirm that the information set forth herein is true and correct under penalty of perjury and that, as applicant, these
answers were given by me. I furthermore affirm that I am familiar with the responsibility imposed upon me, as applicant, by regis-
tering under the International Registration Plan, including recordkeeping requirements and the importance of accurate and com-
plete distance accrual records according to the rules and regulations of the International Registration Plan. Authorized signatures
are those of either the applicant, co-applicant (if necessary) or authorized employee of the company and not anyone acting as
my agent.
______________________________________________ __________________________________________________
Authorized Signature
Date
Authorized Signature
Date
______________________________________________ __________________________________________________
Title
Title
If you were assisted by a Licensing Agent, Remittance Agent or Consultant, a signature must be shown.
_________________________________________________________________________________________________
Signature of License Agent, Remittance Agent or Consultant assisting
______________________________________________ ________________________________ ________________
Agency/Entity Name
License Number (if any)
Date
Signature of License Agent, Remittance Agent or Consultant affirms that proper documentation regarding distance recordkeeping has been
given to the registrant for which this Schedule G has been completed. It also confirms that a copy of the International Registration Plan Instruction
Manual has been given to the registrant or the registrant has been informed of the proper place to obtain a copy from the Secretary of
State’s website.
Failure to answer or explain when necessary will constitute denial of registration. Forms without all required signatures will not be accepted.
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