Form OG-1 "Permittee Status Reporting Form" - Illinois

What Is Form OG-1?

This is a legal form that was released by the Illinois Department of Natural Resources - 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 February 1, 2018;
  • The latest edition provided by the Illinois Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form OG-1 by clicking the link below or browse more documents and templates provided by the Illinois Department of Natural Resources.

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Download Form OG-1 "Permittee Status Reporting Form" - Illinois

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Illinois Department of Natural Resources
Office of Oil and Gas Resource Management
One Natural Resources Way Springfield, Illinois 62702-1271
www.dnr.illinois.gov
(217) 782-7756
PERMITTEE STATUS REPORTING FORM
OG-1
MAILING ADDRESS VERIFICATION
(All information must be completed).
PERMITTEE #:
NAME:
ADDRESS:
CITY:
STATE :
ZIP CODE :
PHONE #:
FAX #:
EMAIL ADDRESSES:
OOGRM will allow up to three email addresses.
Collectively, the email addresses must contain 100 or less
characters.
Pursuant to 62 Ill.Adm.Code Section 240.1710, permittee address and status will be used by the Department to provide notice of hearings or other proceedings. Additionally,
permittees are required to provide any address changes to the Department within 30 days after the effective date of the change in mailing address via the OG-1 form and shall
ensure forwarding of mail from the previous address.
Permittee Status
(All applicable information must be reported.)
1. Identify your business structure:
Sole Proprietorship
Limited Liability
Partnership
Corporation
Company
(individual owner)
2. Does the Permittee name listed on the Annual Well Fee Bill own the right to drill, produce and allocate
production from the wells shown on the Fee Bill?
YES
NO
a. If NO, explain the relationship of the Permittee to the owner of the rights to drill, produce, and
allocate production.
3. Is the Permittee name listed on the Annual Well Fee Bill an assumed business name?
YES
NO
a. If YES, is the assumed business name registered as required by the Assumed Business Name
Act?
YES
NO
b. If YES, in what County or Counties?
c. Doing Business As (d/b/a):
4. Does the Permittee have a Federal Employee Identification Number (FEIN)?
YES
NO
a. If YES, the Permittee is required to report the FEIN:
5. If the Permittee is a Sole Proprietorship (Individual Owner) provide the following:
a. Complete Legal Name:
b. Social Security Number:
Printed by the State of Illinois
DNR OOGRM Form IL OG-1 (Rev. 2/2018)
Page 1 of 2
Illinois Department of Natural Resources
Office of Oil and Gas Resource Management
One Natural Resources Way Springfield, Illinois 62702-1271
www.dnr.illinois.gov
(217) 782-7756
PERMITTEE STATUS REPORTING FORM
OG-1
MAILING ADDRESS VERIFICATION
(All information must be completed).
PERMITTEE #:
NAME:
ADDRESS:
CITY:
STATE :
ZIP CODE :
PHONE #:
FAX #:
EMAIL ADDRESSES:
OOGRM will allow up to three email addresses.
Collectively, the email addresses must contain 100 or less
characters.
Pursuant to 62 Ill.Adm.Code Section 240.1710, permittee address and status will be used by the Department to provide notice of hearings or other proceedings. Additionally,
permittees are required to provide any address changes to the Department within 30 days after the effective date of the change in mailing address via the OG-1 form and shall
ensure forwarding of mail from the previous address.
Permittee Status
(All applicable information must be reported.)
1. Identify your business structure:
Sole Proprietorship
Limited Liability
Partnership
Corporation
Company
(individual owner)
2. Does the Permittee name listed on the Annual Well Fee Bill own the right to drill, produce and allocate
production from the wells shown on the Fee Bill?
YES
NO
a. If NO, explain the relationship of the Permittee to the owner of the rights to drill, produce, and
allocate production.
3. Is the Permittee name listed on the Annual Well Fee Bill an assumed business name?
YES
NO
a. If YES, is the assumed business name registered as required by the Assumed Business Name
Act?
YES
NO
b. If YES, in what County or Counties?
c. Doing Business As (d/b/a):
4. Does the Permittee have a Federal Employee Identification Number (FEIN)?
YES
NO
a. If YES, the Permittee is required to report the FEIN:
5. If the Permittee is a Sole Proprietorship (Individual Owner) provide the following:
a. Complete Legal Name:
b. Social Security Number:
Printed by the State of Illinois
DNR OOGRM Form IL OG-1 (Rev. 2/2018)
Page 1 of 2
Permittee Status
(continued)
6. If the Permittee is a Corporation or Limited Liability Company (LLC), provide the following:
a. Is the Corporation or LLC registered to do business in Illinois?
YES
NO
b. List Registered Agent:
Name
Address
c. List complete legal names of Corporate officers or LLC members or managers:
President
Manager
Member
Vice President
Member
Secretary
Treasurer
Member
d. List Secretary of State Corporation / LLC file number:
7. If the Permittee is a Partnership provide the following:
a. Type of Partnership:
b. Doing Business As (d/b/a):
c. List complete legal names of Partners
:
(S.S.# is voluntary)
S.S.#
S.S.#
S.S.#
S.S.#
8. If the Permittee is an entity other than a Corporation, LLC, Partnership or Sole Proprietorship, please
describe the nature of the Permittee's organization:
List below the complete legal name(s) of person(s) having current Power of Attorney with authorization to sign applications,
bonds, etc... on your (or company/corporation) behalf and provide a certified copy of the Power of Attorney.
Complete Legal Name of Person Completing Form for the Permittee (please print –
Signature of Person Completing Form
person must have authority to complete and sign form for the Permittee)
Date of Signature
This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 225 ILCS 725 et.seq. Disclosure of this information is REQUIRED. Failure to provide any
information may result in a fine up to $250.
Printed by the State of Illinois
DNR OOGRM Form IL OG-1 (Rev. 2/2018)
Page 2 of 2
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