Illinois Form Reg 10 – Fill Out and Use This PDF

If you purchase natural gas from outside of Illinois for use in Illinois (not for resale) you may choose to become a self-assessor of Gas Use Tax unless you are exempt from Gas Use Tax(See below.). A registered self-assessing purchasermust report and pay the Gas Use Tax directly to us rather than to their supplier. After we process your completed Form REG-10, we will issue you a certificate of registration for you to provide to your supplier. Your certificate of registration is proof that you will be responsible for reporting and paying of the Gas Use Tax. If later, any information you provide below should change, you must complete a new Form REG-10. If no changes are needed, you should submit a new Form REG-10 every five years to keep records current. If you have any questions, call us weekdays between 8:00 a.m. and 4:30 p.m. at 217 524-5406 or 217 785-6602.

To be exempt, you must purchase natural gas from outside of Illinois that will be used in Illinois

•by a business located in an enterprise zone;

•by a governmental body or entity organized and operated exclusively for charitable religious, or educational purposes;

•in the production of electric energy;

•in a petroleum refinery operation;

•in liquefaction and fractionation processes that produce value added natural gas by-products for resale; or

•in the production of anhydrous ammonia and nitrogen fertilizer for resale.

Do not completeFormREG-10ifyouareexemptfromGasUseTax.YoumustcompleteFormRG-61,GasUseTaxExemption Certificate.

Step 2: Identify yourself - Individuals only

1	Name:______________________________________________			3	Address:____________________________________________
2	Social Security number: ___ ___ ___ - ___ ___ -___ ___ ___ ___				___________________________________________________
					City	State	ZIP
					_____________________	(_____)_____-______________
					County	Telephone number
Step3: Identify your business - Businesses only
Note: If you are already registered for Gas Revenue Tax,you do not need to complete this application:
4	Name:______________________________________________			7	IllinoisBusinessTaxno.:	___ ___ ___ ___ - ___ ___ ___ ___
5	Corporate name:______________________________________			8	FederalEmployerIdentificationno.: __ __-__ __ __ __ __ __ __
6	Address: ____________________________________________
	Number and street
	___________________________________________________
	City	State	ZIP
	_____________________	(_____)_____-______________
	County	Telephone number

Step 4: Identify your delivering supplier(s)

If you need to identify more than provided for, attach additional sheet(s).

9 ___________________________________________________	___________________________________________________
Name	Name
___________________________________________________	___________________________________________________
Name	Name
___________________________________________________	___________________________________________________
Name	Name

Step 5: Complete and sign below

Check here to acknowledge that no exemption listedin Step 1 applies to you or your business or organization.

Underpenaltiesofperjury,IstatethatIhaveexaminedthisapplicationand,tothebestofmyknowledge,itistrue,correct,andcomplete.

_______________________________________________________		______________________________________________________
Signature	Date	Typed or printed name of person signing to the left
Mail your completed Form REG-10 to
REGISTRATION AND RETURNS PROCESSING		If you have any questions, call our Springfield office weekdays
ILLINOISDEPARTMENTOFREVENUE		between 8:00 a.m. and 4:30 p.m. at 217 524-5406 or 217 785-6602.
POBOX19019
SPRINGFIELD IL 62794-9019