2022 ILLINOIS TIMBER BUYERS LICENSE APPLICATION
ANNUAL LICENSE
EXPIRES DECEMBER 31, 2022
N
ovember 2, 2021
Name of Applicant: ___________________________________________________________________________
Name in which license is to be issued and timber purchased, license can only be issued in one name.
Applicant is: [ ] INDIVIDUAL Applicant FEIN Number
[ ] CORPORATION _____________________________________
[ ] PARTNERSHIP Timber Buyer’s License Number
[ ] LIMITED LIABILITY COMPANY
*** Out of State LLC/Corp must be registered with Illinois Secretary of State
[ ] OTHER (SPECIFY): ______________________________________________________________
P
HYSICAL LOCATION OF PRINCIPAL OFFICE
STREET: ______________________________ ________________________________________
MAILING ADDRESS: _________________________________________________________________________
CITY: ___________________________ STATE: ______________ ____ZIP: ________________ ____________ _
COUNTY: _____________________________________________________________________________________
PHONE NUMBER: _________________ ______E-MAIL: _______________________________________________
LIST COUNTIES (GENERAL AREA) IN WHICH TIMBER WILL BE BOUGHT: ____________________________________
______________
IF APPLICANT IS A CORPORATION, PARTNERSHIP or REGISTERED BUSINESS ORGANIZATION, attach Articles of
Incorporation/Organization filed with the Illinois Secretary of State (Telephone 217/782-7880) and list all persons authorized to act
on behalf of the Applicant. If Applicant is doing business in a name other than his own under The Assumed Business Name Act, 805
ILCS 405, attach Certificate of Registration from the applicable County Clerk’s Office.
LIST ALL AUTHORIZED AGENTS TO REPRESENT THE ABOVE LICENSEE (INCLUDING SELF):
NAME: ___________________________ NAME: ___________________________ NAME: _____________________________
ADDRESS: _________________________ ADDRESS: _________________________ ADDRESS:___________________________
__________________________________ __________________________________ ___________________________________
DATE OF BIRTH: _____________________ DATE OF BIRTH: _____________________ DATE OF BIRTH: ______________________
PHONE: ____________________________ PHONE: ____________________________ PHONE: _____________________________
BUSINESS RELATIONSHIP BUSINESS RELATIONSHIP BUSINESS RELATIONSHIP
TO APPLICANT: ______________________ TO APPLICANT: ______________________ TO APPLICANT: _______________________
SOCIAL SECURITY # (REQUIRED) SOCIAL SECURITY # (REQUIRED) SOCIAL SECURITY # (REQUIRED)
_________-_______-_________________ _________-__________-______________ __________-__________-______________
Additional names may be listed on a separate sheet, including the same information as above. The Holder of the Timber Buyer’s
License is responsible for the use of these cards and the actions of its’ Authorized Agents. Only Agents listed with the Department
may represent the above Licensee and must designate in all contractual arrangements that the above Licensee is the Timber Buyer.
The card must be carried upon the person of the Timber Buyer/Agent while conducting business and must be presented to any
authorized Department Employee or Peace Officer making demand for it. It is the Licensee’s responsibility to provide and maintain
correct addresses.
_____________________________________
2022 ILLINOIS TIMBER BUYERS LICENSE APPLICATION
ANNUAL LICENSE
EXPIRES DECEMBER 31, 2022
November 2, 2021
Give the Total Dollars paid for Timber (Stumpage, Logs, Pulpwood, Piling, Veneer, etc.) bought from Illinois Timber
Growers (Governmental & Private) during the 4
TH
Qtr of 2020(OCTOBER 1, 2020) through the 3
RD
Qtr of 2021
(SEPTEMBER 30, 2021) $ ___________________________
NEW BUYERS ONLY: Estimate of Purchases during license year $ _______________________________________________
BONDING REQUIREMENT IS 10 PERCENT OF THE TOTAL DOLLARS YOU PAID TIMBER OWNERS DURING THE LAST YEAR (OR ESTIMATE FOR NEW
BUYERS) FOR ILLINOIS TIMBER ROUNDED OFF TO THE NEXT HIGHER $100. Maximum of $10,00
----------------------We must have copy of renewal showing current status-----------------------
Bond required for Timber Buyers License Provided by
1. Surety Bond (FORM U-5-73) in the amount of $ ___________ #_____________Issued by___________________
2. Bank Certificate of Deposit $ ________________, Issued by___________________________________________
Original certificate must be filed with Department, and make payable to The Director, Department of Natural
Resources.
3. Irrevocable Letter of Credit $ ___________________#_____________Issued by__________________________
FILING AND CERTIFICATE FEE $30.00 PAYABLE TO: IL DEPARTMENT OF NATURAL RESOURCES-FORESTRY
CERTIFICATION:
Pursuant to 5 ILCS 100/10-65©, IDNR must require license applicants to certify as follows: “I hereby certify, under penalty of
perjury,” that: (check at least one)
[ ] I am not subject to a child support order.
[ ] I am not more than 30 days delinquent in complying with a child support order.
[ ] I am more than 30 days delinquent in complying with a child support order.
[ ] I have not been convicted of any Timber offenses nor been suspend/revoked for any timber offenses in any other States.
DISCLOSURE OF APPLICANT’S SOCIAL SECURITY IS MANDATORY PURSUANT TO 42 U.S.C. 666 (a) (13) and 5 ILCS 100/10-65 FOR USE UNDER THE
STATE’S CHILD SUPPORT ENFORCEMENT PROGRAM. FAILURE TO SO CERTIFY MAY RESULT IN DENIAL OF THE APPLICATION/RENEWAL AND
MAKING FALSE STATEMENTS MAY SUBJECT THE LICENSEE TO CONTEMPT OF COURT [5 ILCS 100/10-65 ©] “I HEREBY CERTIFY THAT THE
INFORMATION CONTAINED HEREIN IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.”
RETURN APPLICATION, ($30) FEE & COPY OF CURRENT BOND TO: PRINTED NAME _______________________________________
Department of Natural Resources
ORC-Division of Forest Resources
SIGNATURE ___________________________________________
One Natural Resources Way
Springfield, IL 62702
Questions: 217-782-2894 SOCIAL SECURITY NUMBER
__________-_______-_________
[email protected] (MANDATORY)
DATE OF BIRTH ______________/_____/___________________
(MANDATORY)
