Entity Name
Provide the name of the company that owns the store or the owner's name if this is a sole proprietorship.
Note that this may be the same as the store name on page 1.
Address, City, County, State, Zip code
This is the address for the company to which all official legal documents must be mailed if sent by USPS mail.
Federal Employer Identification Number (FEIN)
This is the federal tax identification number (FEIN) used to identify a business entity. The FEIN must be a nine-digit number.
Was this business purchased?
Reply yes if you purchased the business from someone.
Reply no if you are starting a new business.
If you replied yes, provide the date of purchase of the business.
Was there a retail grocery business at the location of this vendor before the current ownership?
Reply yes if a grocery store was previously operating at this location.
Reply no if no grocery store was previously operating at this location.
Reply unknown if you do not know what type of business previously operated at this location.
Provide the name of the previous business that operated at this location.
Does the applicant, owner, manager, or employee have any relationship with the previous owner?
A relationship includes, but is not limited to, a partner, shareholder, stockholder, member, immediate or extended family member, corporate officer, manager, employee, or other type of relationship.
If yes, provide the name of the person with whom the relationship is based and the type of relationship with the previous owner.
Please select the type of ownership that applies to your business.
Go to www.ilsos.gov/departments/business_services or consult with a tax professional for assistance in determining the business structure and ownership type for the company that owns the store listed on page 1 of the application.
- Sole Proprietor
- An unincorporated business with just one owner who pays personal income tax on all profits earned.
- Partnership or LLP
- A partnership is an arrangement between two or more people to oversee business operations and share profits and liabilities. Usually, all members share both profits and liabilities.
- Corporation, Cooperative or Limited Liability Corporation (LLC)
- Corporation - A company or group of people authorized to act as a single entity (legally a person) and recognized as such under the law.
- Cooperative - A user-owned and controlled business from which benefits are derived and distributed equitably based on use or as a business owned and controlled by the people who use its services.
- Limited Liability Corporation (LLC) - A private company whose owners are legally responsible for its debts only to the extent of the amount of capital they invested.
- Other
- If your company's business structure is not one of the ones listed above, select Other and provide the type of business that best represents you. Examples may be not-for-profit.
Do you have multiple locations operating under the same FEIN?
If yes, you will be asked to attach a document listing the names and addresses of all stores operating under the same FEIN in Illinois.
Have any owners/partners/shareholders/managers previously owned or operated another grocery store or pharmacy in Illinois?
If yes, you will be asked to attach a document listing the stores or pharmacies' names, addresses, and the years they were owned or operated.
Officer and Owner Information
Provide the information for each owner, partner, limited liability partner, or shareholder of 5% or more of any stock or any officer of the corporation.
How many partners, limited partners, shareholders, owners, or officers are in the Ownership?
If you respond Three (3) or more, you must provide information on an attached document.
Percentage of Ownership
The percentage of ownership that the owner has for the company. Note that the combined total of all owners cannot exceed 100%.
