Confirmation Number: 0-699-397-216

Date Submitted: 07/24/2019

Date Printed: 07/24/2019

Illinois Department of Revenue

REG-1 Illinois Business Registration Application
Step1: Identify your business or organization
6 Check the organization type that applies to you:
1 Federal employer identification number(FEIN)

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Proprietorship
FEIN: 83-0950789
Check if owned by a married couple or civil union

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Proprietorships must provide the Social Security number(SSN)
under which taxes will be filled. Partnership Trust or estate

Corporation* X S Corp (Subchapter S Corporation)*

SSN:
* Is your corporation publicly traded? Yes X No
2 Legal business name:
if yes, provide the ticker symbol

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AAFIYAH SOLUTIONS INC.
Governmental unit Not-for-profit organization
3 Doing-business-as (DBA), assumed, or trade name, if different
from Line 2: LLC - Corporation LLC - Partnership

COMPASSIONATE CARE PHARMACY LLC - Single member

Check if disregarded
4 Primary or legal business address:
7 Illinois Secretary of State identification number:
23 S ELM ST
Street address - No PO Box number Apartment or suite number
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PALATINE IL 600676009 8 Is your business part of a unitary group? Yes X No
City State Zip
If "Yes", provide the FEIN of your designated agent (the entity
If you have other locations in Illinois from where you do responsible for filing your Illinois income tax return):
business, complete and attach Schedule REG-1-L.
FEIN:
5 Mailing address if different from the address above: 9 Identify a contact person regarding your business
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Name: MOHAMMED HUSSAIN Title:
In-care-of name
Phone: 480-290-9538 Ext:
Street address - No PO Box number Apartment or suite number FAX:

Email address: mohammedhussain@hotmail.com

City State Zip
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Step 3: Tell us about your business activities
Use
Describe your business activities: Pharm
11 Does your supplier collect Illinois sales tax for merchandise
OtherRetail
your business uses or consumes in Illinois?
Provide your North American Industry Classification System
Yes X No
(NAICS) number:
Refer to the website www.nacis.com. Does your supplier collect Illinois Sales Tax on sales of
aviation fuel your business uses or consumes in Illinois?
12 Will you have Illinois employees? X Yes No
Yes X No
If yes, complete and attach Schedule REG-UI-1.
When will (did) these activities begin?
When was (is) the date of your first payroll in Illinois?
10/22/2019 Cigarettes and other tobacco products

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13 Check all that apply to your type of business. Cigarettes - See Schedule REG-1-C before you check here.
Sales Tobacco products - See Schedule REG-1-C before you
check here.

You must complete and attach Schedule REG-1-L to identify
all Illinois locations from which you make retail sales.
X General Merchandise: X Retail Wholesale
Note:You must check “Retail” above if you make retail
sales that are filled from inventory that is maintained in
Illinois prior to its delivery to your Illinois purchaser.
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Cigarette machine operator - See Schedule REG-1-C before
you check here.
When will (did) these activities begin?
Renting or leasing
Hotel rooms for less than 30 days- Attach Schedule REG-1-L.
Do you charge for telecommunication services?

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Sales to Illinois customers from out of state
Yes No
Check here if you have an Illinois presence,
including, but not limited to having an office or Vehicles for one year or less- Attach Schedule REG-1-L.
other facility in Illinois or having employees or other Vehicles for more than one year
representatives operating in Illinois.
Rental Purchase Agreements (rent-to-own)
Check here if you make $100,000 or more in
annual sales to Illinois customers. When will (did) these activities begin?
Check here if you make 200 or more separate Utility providers
transactions annually to Illinois customers. Electricity: Retail Wholesale
Do you estimate your monthly sales and use tax liability Natural gas: Retail Wholesale
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will be under $200? Yes X No Telecommunications - See Schedule REG-1-T.
Soft drinks (other than fountain soft drinks) in Chicago Retail Wholesale
Vehicle, watercraft, aircraft, or trailers Water or sewer services
Sales or delivery of tires. Do you always pay the Are you a utility cooperative? Yes No
Tire User Fee to your supplier? Yes No Are you a municipality? Yes No
Sales from vending machines. How many vending When will (did) these activities begin?
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machines?
All other tax types
Liquor at retail (bar, tavern, liquor store, etc.)
Motor fuel/fuel: Retail Wholesale Liquor warehousing- Attach Schedule REG-1-A.
Check here if you are required to collect prepaid Dry Cleaning: Facility Solvent supplier
sales tax. Own/operate coin-operated amusement devices
You wish to purchase electricity for non-residential use
Medical cannabis - Attach Schedule REG-1-MC.
Cultivation Center Dispensing Organization and pay the tax to IDOR - Attach Schedule REG-1-D.
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You wish to purchase natural gas from outside of

Aviation fuel: Retail Wholesale
Illinois for your own use and pay the tax to IDOR - Attach
Services Schedule REG-1-G.
Do you transfer items, on which tax must be collected, as part Not listed. Identify:
of your service? X Yes No
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When will (did) these activities begin?

When will (did) these activities begin? 10/22/2019

Step 4: Sign below

Under penalties of perjury, I state that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Printed name: MOHAMMED HUSSAIN Title: Date: 07/24/2019
Address: 23 S. ELM STREET SSN: ***-**-1980
PALATINE IL 60067 Phone:
 Illinois Department of Revenue
Schedule REG-1-O Owner and Officer Information

If your organization is a: then complete Step 2 to identify:

Proprietorship — the owner (if married couple or civil union, enter both individuals information)
Partnership — each general partner
Corporation* or S Corp — the president, secretary, and treasurer
*If publicly traded (identify below) — the chief operating officer and chief financial officer
Trust or estate — each trustee or executor
— the president, secretary, or treasurer

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Not-for-profit organization
Limited liability company — each manager and member
Governmental unit — one contact person (for example, the liaison)

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Step 1: Identify your business or organization

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Business name: AAFIYAH SOLUTIONS INC. FEIN: 83-0950789
If your business is a corporation, are you publicly traded? Yes X No
SSN:
If "Yes", provide the ticker symbol: Proprietorship only

Contact for this schedule: MOHAMMED HUSSAIN Phone: 480-290-9538

Step 2: Identify your owners and officers

Individuals:
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HUSSAIN, MOHAMMED Sec,Treas
Name Title

23 S ELM STREET PALATINE IL 60067

Home address - NO PO Box number City State Zip

09/02/1980 480-290-9538
Date of birth Phone
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330-90-1980 Ownership percentage: 0
Social Security number

BEGUM, KHUTEJA Pres

Name Title

23 S ELM STREET PALATINE IL 60067

Home address - NO PO Box number City State Zip

07/01/1985 480-299-8147
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Date of birth Phone

330-06-2546 Ownership percentage: 0

Social Security number
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 Illinois Department of Revenue
Schedule REG-1-L Illinois Business Site Location Information

Business name: AAFIYAH SOLUTIONS INC. FEIN: 83-0950789

Contact for this schedule: MOHAMMED HUSSAIN SSN:

Proprietorship only
Phone: 480-290-9538

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Step 1: Identify each permanent location
DBA name: COMPASSIONATE CARE PHARMACY

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Address: 1041 W GOLF RD
Street address - No PO Box number Apt or suite no

HOFFMAN ESTATES IL 601691339

City State Zip

County: Cook

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If in Madison or St. Clair county, list township:

Contact: Phone:
Starting date for this location: 10/22/2019
Check all of your activities at this location:

X Retail sales Aviation Fuel

Vehicles: Sales Renting/leasing

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Check all of your rental/lease agreements are for more than 12 months:

Hotel room rental to the public for periods less than 30 days.

Do you charge for telecommunication services? Yes No

Rental Purchase Agreement
Other:
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 Illinois Department of Revenue
Schedule REG-1-R Responsible Party Information
Step1: Identify your business or organization

Business name: AAFIYAH SOLUTIONS INC. FEIN: 83-0950789

If your business is a corporation, are you publicly traded? Yes X No SSN:

Proprietorship only
If "Yes", provide the ticker symbol:

Contact for this schedule: MOHAMMED HUSSAIN Phone: 480-290-9538

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Step 2: Identify the person(s) responsible for filing your business’ returns and paying all tax due

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Printed legal name: MOHAMMED HUSSAIN SSN: 330-90-1980
Legal address: 23 S ELM ST HOFFMAN ESTATES IL 600676009 Phone: (480)290-9538

Check all for which you are responsible:

X Sales and use taxed and fees Motor fuel and related taxes All taxes and fees Rental purchase agreement tax

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Motor vehicle renting tax Excise taxes and fees - Identify tax/fee:

X Withholding income tax X Unemployment insurance Other:

Under penalties of perjury, I state that I have examined this information and, to the best of my knowledge, it is true,
correct, and complete. I further attest that I will be responsible for filing returns and paying the taxes indicated. I
understand that, by checking “Agree”, I permanently affix my signature pursuant to the Electronic Commerce Security Act,
5 ILCS 175/1-101 through 99-1.

Signature: HUSSAIN, MOHAMMED Title: Date: 07/24/2019

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 Illinois Department of Employment Security and the Illinois Department of Revenue

REG-UI-1 Report to Determine Liability Under the

Unemployment Insurance Act
Read this information first
Register faster using MyTax Illinois, our online account management program, at mytax.illinois.gov. If you have questions contact us weekdays
between 8:30 a.m. and 5:00 p.m. at (800) 247-4984.
Important: Every newly created employing unit shall file this report within 30 days of the date upon which it commences business (820 ILCS
405/1800; 56 Ill. Adm. Code 2760.105). If you are registering a new business, complete and attach this form to your REG-1, Illinois Business
Registration Application, available on the Illinois Department of Revenue website at tax.illinois.gov.
Step 1: Business Information
AAFIYAH SOLUTIONS INC. COMPASSIONATE CARE

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1 Business Name: 2 Doing Business As:
PHARMACY
23 S ELM ST PALATINE IL 600676009
3 Primary Business address:

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(If address is a non-Illinois headquarters you are required to also answer questions 4)

4 Secondary address:
(Physical location of your Illinois business or a secondary address where you conduct business in Illinois. If there is no additional address leave blank. If you want
IDES correspondence sent (Physical location of your Illinois business or a secondary address where conduct business in Illinois. If there is no additional address
leave blank. If you want IDES correspondence sent to any other address than question 3 and 4, complete and attach IDES Form UI-1 Special Mailing Form and
LE-10, Power of Attorney, if applicable)

5 Phone Number: 6 Email Address: mohammedhussain@hotmail.com

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7 FEIN: 83-0950789 8 IDES previously assigned employer account no.:
(If applicable)

9 Type of organization (check one): Association Cooperative C-Corporation Government Municipal Government
Political Subdivision Instrumentality LLC-Corporation LLC-Partnership LLC-Single Member Partnership
Receiver X S-Corporation Sole Proprietor Trustee in Bankruptcy Trust/Estate Other:
(Describe)
10 Is this a qualified settlement fund? Yes X No

Step 2: Entity Information 18 Did you acquire your Illinois business or any portion of it by purchase,
reorganization or a change in entity; for example, a change from sole
11 What is your primary business activity in Illinois? Yes
proprietor to corporation? X No
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If yes, you must complete and attach form UI-1 S&P, Report to Determine Succession. Also
complete the remainder of the questions on this form. Responses to the questions on this form
What is your principal product or service? should reflect information relative to the operation of your business after the date of
acquisition.

If you have more than one product or service, list the top two and Step 3: Liability Information
indicate the percentages that each contributes to your total revenue:
19 Have you incurred liability under the Federal Unemployment Tax Act
% of Sales or receipts (in any state) for any of the last 4 years? Yes No
X
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% of Sales or receipts
If yes, indicate the year(s) for which you incurred such liability:
Enter your NAICS Code here 446110
(If you do not know your NAICS Code refer to the Bureau of Labor Statistics website for the
proper code) Step 4: Additional Liability Information
12 If you are a Corporation: If you are not engaged in Domestic, Agricultural, Religious,
06/04/2019 IL
Date of Incorporation State in which incorporated Charitable, Educational, Nonprofit or Governmental services, skip to
Has any form of remunerations, including dividends, been paid to the question 24.
officers of this corporation? Yes X No 20 Domestic Service Entities
13 If you are a Limited Liability Company (LLC): In regards to domestic service workers in a private home, local college
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club, or local chapter of a college fraternity or sorority, if applicable

Are there any individuals performing services for the organization other
check any of the following:
than the member manager(s)? Yes No
a If during the current calendar year, the past four calendar
How is the member manager(s) treated for federal tax purposes?
years, or the future four calendar quarters, have there or
Sole Proprietor Partner Other (Explain) will there be any quarter in which you paid wages of
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If you are an LLC-Corporation indicate: $1,000 or more for domestic service.

IL Check the first such quarter during that period and indicate the year in
Date of Organization State in which Organized
which it will or did occur:
14 If you are a Partnership: Quarter:
Are there any individuals performing services other than the partners?
b If you solely employ household workers and are eligible
Yes No
to use Schedule H (IRS Form 1040) for filing federal
15 If you are a Sole Proprietor: unemployment taxes for the workers (whether or not you
Are there any individuals performing services, other than the sole proprietor, use it), then you may elect to pay contributions for each
the sole proprietor’s parent, spouse or child under the age of 18? quarter and submit wage reports for each month or
quarter, as the case may be, on an annual basis. Check
Yes No this box (20b) if you are eligible and would like to elect to
10/22/2019 file annually.
16 Date you first began employing workers in Illinois:
10/22/2019
17 Date of your first payroll in Illinois:
21 Agricultural Entities
In regards to agricultural labor, if applicable check any of the following:
a You employ, have employed, or will employ one of more workers
to perform agricultural labor.
b During the current calendar year, the past four calendar years, or
the future four calendar quarters, have there or will there be any
quarter in which you paid wages of $20,000 or more for
agricultural labor?
If so, check the first such quarter during that period and indicate the year
in which it will or did occur:
23 Governmental Entities or Indian Tribes
a Check if you wish to be a reimbursable employer. Complete
and attach form UI-5LG, Reimburse Benefits in Lieu of
Paying Contributions.
b Check if your organization is an Indian Tribe (including a
subdivision, subsidiary or business enterprise wholly owned
by an Indian Tribe).
24 If you didn’t answer 20, 21, 22, 23, check any of the following
boxes that apply and provide the requested information.
a X Have there or will there be, any calendar quarter in either the
current calendar year, the past four calendar years, or the
future four calendar quarters, in which you paid wages of at

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Quarter: least $1,500 for services in employment?

If so, check the first such quarter during that period and indicate the

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c During the current calendar year, the past four calendar years, or year in which it will or did occur:
the future four calendar quarters, have there or will there be any
calendar year during which you employed 10 or more individuals
to perform agricultural labor for at least 20 weeks (whether Quarter:
consecutive or not)?
If so, check the first such quarter during that period and indicate the year
b Have there or will there be, any calendar quarter in either the
in which it will or did occur:
current calendar year, the past four calendar years, or the future

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four calendar quarters, in which you have had one or more
Quarter: individuals performing services in employment in each of at
least 20 weeks (whether consecutive or not)?

If you checked 21a, 21b or 21c and your business includes any If so, check the first such quarter during that period and indicate the
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retail sales activity, check this box (21d). year in which it will or did occur:

22 Religious, Charitable, Educational or Other Nonprofit Entities Quarter:

a Check if your organization is a religious, charitable, educational or
other nonprofit organization as defined in Section 501(c)(3) of the
Internal Revenue Code. If so, attach your federal IRS 501(c)(3) Step 5: Additional Business Information
exemption letter to this application.
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25 Voluntary Coverage
b During the current calendar year, the past four calendar years, or
the future four calendar quarters, have there or will there be any If you are determined to be not liable for the payment of
quarter in which you have had four or more workers to perform unemployment insurance taxes based upon the provisions of the
work for at least 20 weeks (whether or not consecutive)? Illinois Unemployment Insurance Act you may voluntarily elect
coverage under 820 ILCS 405/302.
If so, check the quarter that included the 20th week within which you have
employed 4 or more individuals to perform religious, charitable education Check if you want voluntary coverage, complete and
and/or nonprofit labor and indicate the year in which it will or did occur: attach Form UI-1B, Voluntary Election of Coverage.
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Quarter: 26 If you have multiple worksites in Illinois complete and attach Form
UI-ML, Multiple Worksites in Illinois, found online at ides.illinois.gov.
c Check if you wish to be a reimbursable employer. Complete and
attach form UI-5NP, Reimburse Benefits in Lieu of Paying
Contributions.

Step 6: Certification and Signature

I hereby certify that the information contained in this report, and any sheets or forms attached hereto, is true and correct. This report must
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be signed by the owner, a partner, or an authorized agent within the employing enterprise. If this document is signed by any other person,
complete and attach the Illinois Department of Employment Security Form LE-10, Power of Attorney, available online at ides.illinois.gov.
Printed name: MOHAMMED HUSSAIN Signature: MOHAMMED HUSSAIN
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Title: Date: 07/24/2019

Confirmation Number: 0-699-397-216

Date Submitted: 24-Jul-2019
Date Printed: 07/24/2019