QNBV Application

Program Year
{programYear} Illinois Angel Investment Tax Credit Program

Qualified New Business Venture

Application

You will need to have two documents prepared to upload for this application.
1. A screen capture of a current and active Illinois Secretary of State Certificate of Good Standing, which can be found here.
2. Current capitalization table information entered into this template.
Upon submission, a confirmation email will be sent to the email address provided below for contact information. This email will also include a PDF of the responses submitted which you can keep for your records.

Any incomplete or deficient applications will be denied with a reason and opportunity to appeal. This will delay any approval process, so please be sure to submit a complete and accurate application.

The review committee meets every other week so please allow at least two weeks for a determination.

In order for investor applications to be considered, investments must be made on or after the approval date (or "certification date") and within the same calendar year ({programYear}).

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!
APPLICATION INFORMATION
Type of Application*

Initial ApplicationAppeal
Please provide a detailed explanation regarding the reason for your appeal.
APPLICANT INFORMATION
Business Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the applicant's headquarters located in Illinois?*

YesNo
Is the headquarter address different than address listed above?*

YesNo
Headquarters Address

Street Address

Street Address Line 2

CityState

Zip Code
County*
Is the applicant’s principal place of business in Illinois?*

YesNo
Please provide detail for the choice above.
NAICS Code*
FEIN*
Website URL
Please explain if no URL is provided.
Has this business been previously certified as a QNBV in this program?*

YesNo
How did you hear about the Illinois ANGEL TAX CREDIT PROGRAM?
Please Specify:
All previous QNBV registration numbers
Separate by using a comma.
CONTACT INFORMATION
Name*

First NameLast Name
E-mail*
example@example.com
Telephone*
ELIGIBILITY INFORMATION
This program provides a set-aside of funds for companies that are minority owned, women owned, or owned by a person with a disability.*

*As those terms are used and defined in the Business Enterprise for Minorities, Woman, and Persons with Disabilities Act.
Does this business qualify for the "set-aside" designation? (NOTE: Business does not need to have the certification - only needs to meet qualifications as the terms are used and defined in the Act above.)*

YesNo
Please select all that apply.

Minority-OwnedWomen-OwnedOwned by a Person with a Disability
Please select all that apply.

American Indian (Native American) or Alaska Native-OwnedAsian American-OwnedBlack/African American-OwnedLatinx/Hispanic-OwnedNative Hawaiian or Other Pacific Islander-OwnedOther
Please upload supporting documentation for the designation.

Browse Files
This could be a copy of a passport, state ID, driver's license or any certifications obtained. Multiple files allowed. Cancelof
How many months has this business been in operation in Illinois?*
Number of years business has been in operation in Illinois.
Does this business intend to operate in Illinois for a minimum of three additional years?*

YesNo
Please provide detail for the choice above.
Total number of employees as of today*
"Employees" includes founders, FTEs and FTE equivalents.
Number of employees employed in Illinois as of today*
"Employees" includes founders, FTEs and FTE equivalents.
% employees employed by business in Illinois.
Are at least 51% of the employees employed by the business based in Illinois?

YesNo
Does this business have the potential to increase jobs in Illinois?*

YesNo
Please provide detail for the choice above.
Please provide an estimated number of jobs this business plans to create in Illinois in the current year.
Does this business agree to maintain at least 51% of total employee positions for the business in Illinois for at least three years from the issue date of the last tax credit or maintain the principal place of business in Illinois?*

YesNo
Does this business agree to maintain at least 75% of employee positions created in Illinois for at least three years from the issue date of the last tax credit?

YesNo
Total aggregate investments received to date. ($)*
*NOTE* If this does not equal the total on your cap table, the application will be denied and you will need to submit an appeal.
Does this business have the potential for increasing capital investment in Illinois?*

YesNo
Please provide detail for the choice above.
Please provide an estimated amount of capital to be raised. ($)
Does this business have a current and "Active" Illinois Secretary of State Certificate of Good Standing? (NOTE: This is required to be eligible for the program.)*

YesNo
Please upload the "Illinois Secretary of State Certificate of Good Standing"

Browse Files
Information for how to obtain this can be found at the beginning of this application. Cancelof
Please upload your business's cap table information (using the template provided at the beginning of the application) here.*

Browse Files
*Please note: If your cap table does not directly reflect the dollar amount invested by each investor and a total equaling your entry for Total Aggregate Investments Received to Date above, you will have to resubmit and this slows down the application process.* Cancelof
INNOVATION
Please provide a one sentence description of your business.*
If you are approved, this sentence will be shared on the public list for all investors to see.
Please describe this business’s products and/or services.*
What problem(s) does this business’s products and/or services solve?*
Please describe why this business’s products and/or services should be considered innovative.*
How will this innovation be utilized in the marketplace?*
Does this business own the innovative products and/or services described above?*

YesNo
Does this business hold a patent (or has the business applied for a patent) for the products and/or services?*

YesNo
Patent Number
Please select your industry.*

AgricultureEnergyInformation TechnologyLife Sciences / HealthcareManufacturingTransportation / LogisticsQuantum Information ScienceOther
Please select the area that your business is principally engaged in, if applicable. Otherwise, please choose "Not Involved with any of the above". NOTE: This is not your customer base, but rather area your business itself is engaged in.*

Real Estate DevelopmentInsuranceBankingLendingLobbyingPolitical ConsultingProfessional Services Provided by AttorneysProfessional Services Provided by AccountantsProfessional Services Provided by Business ConsultantsProfessional Services Provided by PhysiciansProfessional Services Provided by Health Care ConsultantsWholesale or Retail TradeLeisureHospitalityTransportationConstruction*Not Involved with Any of the Above
* Except construction of power production plants that derive energy from a renewable energy resources as defined in Section 1 of the Illinois Power Agency Act which can be found here.
Please provide detail for the choice above.
Which of the following best describes the area of innovation this business is principally engaged in?*

ManufacturingBiotechnologyNanotechnologyCommunicationsAgricultural SciencesClean energy creation or storage technologyProcessing or assembling Medical DevicesProcessing or assembling PharmaceuticalsProcessing or assembling Computer SoftwareProcessing or assembling Computer HardwareProcessing or assembling SemiconductorsProcessing or assembling other innovative technology productsProcessing or assembling other products that are produced using manufacturing method that are enabled by applying proprietary technologyProviding services that are enabled by applying proprietary technologyUndertaking pre-commercialization activity related to proprietary technology that includes conducting research, developing a new product or business process, or developing a service that is principally reliant on applying proprietary technologyOther area not included above
Please provide detail for the choice above.
CERTIFICATION
Authorized Executive Officer / Individual:
Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Signature*

Clear
Rural?
WMD?
PPofBIZinIL
> 51%empIL
PotINCjobs
PotINCinv
PrinENG
Cert Accepted
QNBV#
NOTprinENG
< 100emps
< 10yrsbiz
< 10Minv
MaintainEMP
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:

APPLICATION INFORMATION

APPLICANT INFORMATION

CONTACT INFORMATION

ELIGIBILITY INFORMATION

INNOVATION

CERTIFICATION