Instructions for Form Reg-4-a - Financial Responsibility Bond

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General Information
Who must submit a bond?
What is required for Form REG-4-A?
Form REG-4-A, Financial Responsibility Bond, or Form REG-4-D,
All signatures and seals must be original. We will not accept copies,
Financial Institution Irrevocable Letter of Credit Bond, is required to
faxes, etc., as proof of bond coverage. Duplicate originals must
complete your registration to be licensed as a
be marked as such and must meet the same requirements as the
original bond form. You must attach a power of attorney stating the
• cigarette distributor
• tobacco products distributor
attorney-in-fact's name.
• cigarette machine operator
• motor fuel distributor
• liquor distributor
• motor fuel supplier
If any of the above requirements are not met, we will not accept the
• direct wine shipper
• motor fuel receiver
bond and it will be returned for correction.
• liquor airline
Where do I send my Form REG-4-A?
Note: International Fuel Tax Agreement (IFTA) carriers may be
required to obtain a bond.
Mail your completed Form REG-4-A with any required attachments
to us at
You must complete either Form REG-4-A or Form REG-4-D to
CENTRAL REGISTRATION DIVISION 3-222
obtain a bond. You will not be issued a certificate of registration and
ILLINOIS DEPARTMENT OF REVENUE
cannot be legally registered to do business in Illinois until we receive
PO BOX 19039
your bond.
SPRINGFIELD IL 62794-9039
How do I obtain a bond using Form REG-4-A?
If you have questions regarding Form REG-4-A, visit our website at
tax.illinois.gov or call us weekdays between 8:00 a.m. and 4:30 p.m.
You must provide Form REG-4-A to the insurance company that
at 217 558-7425.
will be providing your bond. A separate bond is required for each
location.
Specific Instructions
Part 1: Financial responsibility bond type and
Surety seal - The corporate seal of the surety company must be
affixed to the bond form.
number
Principal's signatures - The organization type of your business
Line a, Bond type - The bond type must match the tax type for
determines the signature requirements. If your company is a
which the bond is being issued.
Corporation - Two signatures are required. The president and
Line b, Financial responsibility bond number - This number is
corporate secretary must both sign the bond. If no individual
assigned by the surety company and must be present on the bond.
is identified as the corporate secretary, another officer of the
company may sign the bond.
Part 2: Taxpayer and financial institution information
Partnership - Two signatures are required. Two partners must
Taxpayer's name and address - The name and address must be
both sign the bond.
identical to the information that you have registered with us. The
Proprietorship - One signature is required. The sole proprietor
address must be the physical location of your business; mailing
must sign the bond.
addresses, PO Boxes, and other addresses are not acceptable.
Limited Liability Company (LLC) filing as a corporation,
Name and address of surety - The name and address of the surety
partnership, or single member - One signature is required.
company executing the bond must be present.
Any manager or member of the LLC may sign the bond.
Bond amount - The amount of bond coverage must be entered on
Surety signature - A surety company attorney-in-fact must sign
this line.
and print his or her name. The name of the individual who signs for
Notification of cancellation - The surety company may
the surety company must appear on the required power of attorney
conditionally cancel the bond by filing a written notice with IDOR by
attached to the bond.
registered or certified mail within 90 days.
Countersignature - A countersignature is only required if an
independent insurance company is writing the bond agreement on
Part 3: Financial responsibility bond signatures and
behalf of the surety company. Provide the name and address of the
seal requirements
independent agent.
Signed and sealed date - The date the bond was signed by the
Power of attorney - An original power of attorney must accompany
surety company and their seal was affixed to the bond form.
the bond.
Effective date - This is the date the bond coverage will begin.
REG-4-A-I (N-04/13)
General Information
Who must submit a bond?
What is required for Form REG-4-A?
Form REG-4-A, Financial Responsibility Bond, or Form REG-4-D,
All signatures and seals must be original. We will not accept copies,
Financial Institution Irrevocable Letter of Credit Bond, is required to
faxes, etc., as proof of bond coverage. Duplicate originals must
complete your registration to be licensed as a
be marked as such and must meet the same requirements as the
original bond form. You must attach a power of attorney stating the
• cigarette distributor
• tobacco products distributor
attorney-in-fact's name.
• cigarette machine operator
• motor fuel distributor
• liquor distributor
• motor fuel supplier
If any of the above requirements are not met, we will not accept the
• direct wine shipper
• motor fuel receiver
bond and it will be returned for correction.
• liquor airline
Where do I send my Form REG-4-A?
Note: International Fuel Tax Agreement (IFTA) carriers may be
required to obtain a bond.
Mail your completed Form REG-4-A with any required attachments
to us at
You must complete either Form REG-4-A or Form REG-4-D to
CENTRAL REGISTRATION DIVISION 3-222
obtain a bond. You will not be issued a certificate of registration and
ILLINOIS DEPARTMENT OF REVENUE
cannot be legally registered to do business in Illinois until we receive
PO BOX 19039
your bond.
SPRINGFIELD IL 62794-9039
How do I obtain a bond using Form REG-4-A?
If you have questions regarding Form REG-4-A, visit our website at
tax.illinois.gov or call us weekdays between 8:00 a.m. and 4:30 p.m.
You must provide Form REG-4-A to the insurance company that
at 217 558-7425.
will be providing your bond. A separate bond is required for each
location.
Specific Instructions
Part 1: Financial responsibility bond type and
Surety seal - The corporate seal of the surety company must be
affixed to the bond form.
number
Principal's signatures - The organization type of your business
Line a, Bond type - The bond type must match the tax type for
determines the signature requirements. If your company is a
which the bond is being issued.
Corporation - Two signatures are required. The president and
Line b, Financial responsibility bond number - This number is
corporate secretary must both sign the bond. If no individual
assigned by the surety company and must be present on the bond.
is identified as the corporate secretary, another officer of the
company may sign the bond.
Part 2: Taxpayer and financial institution information
Partnership - Two signatures are required. Two partners must
Taxpayer's name and address - The name and address must be
both sign the bond.
identical to the information that you have registered with us. The
Proprietorship - One signature is required. The sole proprietor
address must be the physical location of your business; mailing
must sign the bond.
addresses, PO Boxes, and other addresses are not acceptable.
Limited Liability Company (LLC) filing as a corporation,
Name and address of surety - The name and address of the surety
partnership, or single member - One signature is required.
company executing the bond must be present.
Any manager or member of the LLC may sign the bond.
Bond amount - The amount of bond coverage must be entered on
Surety signature - A surety company attorney-in-fact must sign
this line.
and print his or her name. The name of the individual who signs for
Notification of cancellation - The surety company may
the surety company must appear on the required power of attorney
conditionally cancel the bond by filing a written notice with IDOR by
attached to the bond.
registered or certified mail within 90 days.
Countersignature - A countersignature is only required if an
independent insurance company is writing the bond agreement on
Part 3: Financial responsibility bond signatures and
behalf of the surety company. Provide the name and address of the
seal requirements
independent agent.
Signed and sealed date - The date the bond was signed by the
Power of attorney - An original power of attorney must accompany
surety company and their seal was affixed to the bond form.
the bond.
Effective date - This is the date the bond coverage will begin.
REG-4-A-I (N-04/13)

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