Form REG-4-C Financial Institution Irrevocable Letter of Credit Bond Liquor Gallonage Tax - Illinois

Form REG-4-C or the "Financial Institution Irrevocable Letter Of Credit Bond Liquor Gallonage Tax" is a form issued by the Illinois Department of Revenue.

The form was last revised in December 1, 2011 and is available for digital filing. Download an up-to-date Form REG-4-C in PDF-format down below or look it up on the Illinois Department of Revenue Forms website.

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Illinois Department of Revenue
REG-4-C
Financial Institution Irrevocable Letter of Credit Bond
Liquor Gallonage Tax
Part 1: Financial institution letter of credit bond type and number
Liquor Gallonage Tax
a
Bond type:
b
Provide the fi nancial institution irrevocable letter of credit number:
2
c
Bond amount: Estimate your average monthly liquor tax liability: $____________ X
= $______________
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
Part 2: Taxpayer and fi nancial institution information
Taxpayer
Financial institution
____________________________________________________
____________________________________________________
Name
Name
____________________________________________________
____________________________________________________
Street address
Street address
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
Part 3: Effective and maturity date of bond
Effective date: __ __/__ __/__ __ __ __
Maturity date: __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Part 4: Bond conditions
If the taxpayer identifi ed in Part 2 fails to pay the Illinois Department of Revenue (IDOR) all moneys, including penalties and
interest, due under the Liquor Control Act (Liquor Gallonage Tax), IDOR is authorized to draw drafts on demand against this
irrevocable letter of credit. The sum of the drafts drawn against this irrevocable letter of credit cannot exceed the bond
amount above, in Part 1, and drafts drawn against it are payable on demand. This letter of credit is issued for a period
of one year and will be renewed automatically for successive one year periods unless IDOR receives a written notice of
cancellation 30 days prior to the maturity date.
Part 5: Financial institution offi cer information
The undersigned offi cer of the fi nancial institution identifi ed in Part 2 is duly authorized by the Board of Directors to execute this
irrevocable letter of credit; and in accordance with the terms of this irrevocable letter of credit, this fi nancial institution will honor
all drafts on demand. The name of the authorized fi nancial institution offi cer, title, and his or her signature are required.
Name:____________________________________________
Title: _____________________________________________
Signature:_________________________________________
Part 6: Financial institution seal
The offi cial seal of the fi nancial institution must be affi xed below.
For offi cial use only
Date approved:
___ ___ / ___ ___ / ___ ___ ___ ___
____________________________________________________
IDOR Director's signature
Month
Day
Year
License number:
________________________________
*146001110*
This form is authorized by the Liquor Control Act of 1934. Disclosure of this information
is REQUIRED. Failure to provide information could result in denial of this application.
REG-4-C (R-12/11)
Illinois Department of Revenue
REG-4-C
Financial Institution Irrevocable Letter of Credit Bond
Liquor Gallonage Tax
Part 1: Financial institution letter of credit bond type and number
Liquor Gallonage Tax
a
Bond type:
b
Provide the fi nancial institution irrevocable letter of credit number:
2
c
Bond amount: Estimate your average monthly liquor tax liability: $____________ X
= $______________
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
Part 2: Taxpayer and fi nancial institution information
Taxpayer
Financial institution
____________________________________________________
____________________________________________________
Name
Name
____________________________________________________
____________________________________________________
Street address
Street address
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
Part 3: Effective and maturity date of bond
Effective date: __ __/__ __/__ __ __ __
Maturity date: __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Part 4: Bond conditions
If the taxpayer identifi ed in Part 2 fails to pay the Illinois Department of Revenue (IDOR) all moneys, including penalties and
interest, due under the Liquor Control Act (Liquor Gallonage Tax), IDOR is authorized to draw drafts on demand against this
irrevocable letter of credit. The sum of the drafts drawn against this irrevocable letter of credit cannot exceed the bond
amount above, in Part 1, and drafts drawn against it are payable on demand. This letter of credit is issued for a period
of one year and will be renewed automatically for successive one year periods unless IDOR receives a written notice of
cancellation 30 days prior to the maturity date.
Part 5: Financial institution offi cer information
The undersigned offi cer of the fi nancial institution identifi ed in Part 2 is duly authorized by the Board of Directors to execute this
irrevocable letter of credit; and in accordance with the terms of this irrevocable letter of credit, this fi nancial institution will honor
all drafts on demand. The name of the authorized fi nancial institution offi cer, title, and his or her signature are required.
Name:____________________________________________
Title: _____________________________________________
Signature:_________________________________________
Part 6: Financial institution seal
The offi cial seal of the fi nancial institution must be affi xed below.
For offi cial use only
Date approved:
___ ___ / ___ ___ / ___ ___ ___ ___
____________________________________________________
IDOR Director's signature
Month
Day
Year
License number:
________________________________
*146001110*
This form is authorized by the Liquor Control Act of 1934. Disclosure of this information
is REQUIRED. Failure to provide information could result in denial of this application.
REG-4-C (R-12/11)
You must provide this information to the
fi nancial institution
or insurance company that will be providing your bond.
A separate
bond is required for each location. You will not be issued a certifi cate of registration and cannot be legally registered to do
business in Illinois until we receive your bond. Your bond can be in the form of a
Insurance bond: Form REG-4-B, Financial Responsibility Bond Liquor Gallonage Tax, must be completed entirely by your
insurance company. Your business' name and address must be identical to the information you have registered with us. The
insurance company issuing your bond must
• sign;
• stamp their insurance seal;
• assign a bond number; and
• if applicable, attach their power of attorney stating the attorney-in-fact's name.
All of your business' owners, offi cers, or partners must sign the bond. If you are a corporation, the president and secretary must
sign the bond. You must also affi x your corporate seal. Note: The original bond and power of attorney must be sent to us.
Letter of Credit: Form REG-4-C, Financial Institution Irrevocable Letter of Credit Bond Liquor Gallonage Tax, must be
completed entirely by your fi nancial institution. Your business' name and address must be identical to the information you have
registered with us. The fi nancial institution issuing your letter of credit must
• stamp their fi nancial institution seal; and
• send to us the original bank letter of credit containing the seal.
Note: The Letter of Credit must be signed by an authorized offi cer of the fi nancial institution.
Bond amount: To fi gure the amount of your bond, estimate your average monthly liquor tax liability and multiply by 2.
Note: The minimum bond amount is $1,000 and the maximum amount is $100,000.
*ZZZZZZZZZ*
REG-4-C (R-12/11)

Download Form REG-4-C Financial Institution Irrevocable Letter of Credit Bond Liquor Gallonage Tax - Illinois

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