Form REG-4-A Financial Responsibility Bond - Illinois

Form REG-4-A or the "Financial Responsibility Bond" is a form issued by the Illinois Department of Revenue.

Download a PDF version of the Form REG-4-A down below or find it on the Illinois Department of Revenue Forms website.

Step-by-step Form 4-A instructions can be downloaded by clicking this link.

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Illinois Department of Revenue
REG-4-A
Financial Responsibility Bond
Part 1: Financial responsibility bond type and number
a
Bond type: ____________________________________________
b
Financial responsibility bond number: _______________________
Part 2: Taxpayer and financial institution information
We, _______________________________________________________________________________________ (as principal)
Taxpayer's name and address
and _________________________________________________________________________________________ (as surety)
Name and address of surety
are bound to the people of the State of Illinois in the penal sum of $_____________________. We hereby bind ourselves, our
heirs, executors, administrators, successors, and assigns to the payment of this amount.
The condition of this bond is that if the principal (taxpayer) identified above, who has applied for the tax responsibility (bond
type) identified above, in Part 1, pays to the Illinois Department of Revenue (IDOR) all amounts becoming due from the principal
(taxpayer) under this law, then the bond will become void; otherwise, the bond will remain in full force.
The surety identified above may conditionally cancel this bond at any time by filing a written notice with IDOR by registered or
certified mail within 90 days. However, cancellation does not discharge the surety from any liability previously accrued under this
bond or that may accrue before the 90 days expire.
Part 3: Financial responsibility bond signatures and seal requirements
We have signed and sealed this bond on __ __/__ __/__ __ __ __, to be effective __ __/__ __/__ __ __ __.
You must attach a power of attorney.
(Principal's seal)
(Surety's seal)
__________________________________________
__________________________________________
Principal's (taxpayer) signature
Surety company attorney-in-fact's signature
__________________________________________
__________________________________________
Second principal's signature, if applicable
Attorney-in-fact's printed name
__________________________________________
Countersigned by
President's or co-partner's signature
__________________________________________
__________________________________________
Corporate secretary's signature
Agent for surety
__________________________________________
Number and street
__________________________________________
City
State
ZIP
For official use only
Date approved: __ __/__ __/__ __ __ __
______________________________________
Month Day Year
IDOR Director's signature
License number: _____________________
REG-4-A (R-04/13)
Illinois Department of Revenue
REG-4-A
Financial Responsibility Bond
Part 1: Financial responsibility bond type and number
a
Bond type: ____________________________________________
b
Financial responsibility bond number: _______________________
Part 2: Taxpayer and financial institution information
We, _______________________________________________________________________________________ (as principal)
Taxpayer's name and address
and _________________________________________________________________________________________ (as surety)
Name and address of surety
are bound to the people of the State of Illinois in the penal sum of $_____________________. We hereby bind ourselves, our
heirs, executors, administrators, successors, and assigns to the payment of this amount.
The condition of this bond is that if the principal (taxpayer) identified above, who has applied for the tax responsibility (bond
type) identified above, in Part 1, pays to the Illinois Department of Revenue (IDOR) all amounts becoming due from the principal
(taxpayer) under this law, then the bond will become void; otherwise, the bond will remain in full force.
The surety identified above may conditionally cancel this bond at any time by filing a written notice with IDOR by registered or
certified mail within 90 days. However, cancellation does not discharge the surety from any liability previously accrued under this
bond or that may accrue before the 90 days expire.
Part 3: Financial responsibility bond signatures and seal requirements
We have signed and sealed this bond on __ __/__ __/__ __ __ __, to be effective __ __/__ __/__ __ __ __.
You must attach a power of attorney.
(Principal's seal)
(Surety's seal)
__________________________________________
__________________________________________
Principal's (taxpayer) signature
Surety company attorney-in-fact's signature
__________________________________________
__________________________________________
Second principal's signature, if applicable
Attorney-in-fact's printed name
__________________________________________
Countersigned by
President's or co-partner's signature
__________________________________________
__________________________________________
Corporate secretary's signature
Agent for surety
__________________________________________
Number and street
__________________________________________
City
State
ZIP
For official use only
Date approved: __ __/__ __/__ __ __ __
______________________________________
Month Day Year
IDOR Director's signature
License number: _____________________
REG-4-A (R-04/13)

Download Form REG-4-A Financial Responsibility Bond - Illinois

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