Claimant Annual Attestation of Investment

ILLINOIS ANGEL INVESTMENT TAX CREDIT PROGRAM

Claimant Investor Annual Attestation of Investment
The Department of Commerce and Economic Opportunity shall annually certify that the claimant's investment has been made and remains in the registered, qualified new business venture for no less than three years. If an investment for which a claimant is allowed a credit is held by the claimant for less than three years, the claimant shall pay to the Department of Revenue, in the manner prescribed by the Department of Revenue, the amount of the credit that the claimant received related to the investment.
CLAIMANT INFORMATION
Is the claimant an individual or a business?
Claimant's Name

First NameLast Name
Business Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
CONTACT INFORMATION

Contact Info for All Correspondence (if different than claimant listed above)
Please update contact information if you would like correspondence to be provided to another contact.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
INVESTMENT INFORMATION
QNBV Name
QNBV Number
Investment Amount
Date of Investment

MonthDayYear
Attestation Number
Does the investment referenced above still remain in the QNBV?
If the investment referenced above does not remain in the QNBV, please provide details to explain.
Is the QNBV referenced above still headquartered in the State of Illinois?
If the QNBV is no longer headquartered in the State of Illinois, please provide information regarding the current headquarters or any additional detail.
CLAIMANT ATTESTATION
Please select the method of submission for the Attestation Signature
Please download the certification form here, then attach signed form using the button below.
Certification Form:

Upload File

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Authorized Executive Officer / Individual:
Name

First NameLast Name
Title (if applicable)
Date

MonthDayYear
Date
Tip: When finished, select "Print Form" and save as a PDF before selecting "Preview Answers", then "Submit". This will ensure you have your data backed up in case you encounter any unforeseen connectivity issues!
Signature

Clear
The Department of Commerce and Economic Opportunity (DCEO) is committed to protecting the privacy of its vendors, grantees and beneficiaries of programs and services. At times, DCEO will request social security numbers (SSNs) or other personal identifying information. Federal and state laws, rules and regulations require the collection of this information for certain purposes relating to employment and/or payments for goods and services, including, but not limited to, grants. DCEO also collects confidential information for oversight and monitoring purposes.

Furnishing personal identity information, such as a social security number, is voluntary; however, failure to provide required personal identity information may prevent an individual or organization from using the services/benefits provided by DCEO as a result of state or federal laws, rules and regulations.
Should be Empty:

CLAIMANT INFORMATION

CONTACT INFORMATION

INVESTMENT INFORMATION

CLAIMANT ATTESTATION