CITY OF CHICAGO 
                                                       DEPARTMENT OF FINANCE 
                               AFFIDAVIT FOR INITIAL TAXABLE PERIOD 

I,                                                                                      , as authorized representative, holding the title of 
     (Business Representative)  
____________________________ hereby attest that                                                                                               
                (Title)                                                                             (Business Name)  
located at                                                                                                            and having Chicago 
               (Street Address)                 (City)   (State)                 (Zip code) 
Department of Finance tax account number ___________ - ____________ is liable for remitting                                                        
                                                                                (IRIS No.)                (Site No.) 
and/or collecting the City of Chicago                                                                                . I further 
                                                                                        (Tax Type) 
attest that the first taxable day on which above referenced entity had the legal obligation to 

collect and/or remit for this tax type is                                                             for the following reason(s): 
                                                       (First Date Subject to Tax) 
                                                                                        
I further attest that I have the knowledge and authority to make the above statements. 

I hereby certify, under penalty of perjury, that the information contained in this affidavit is 
true and correct. 

Signature                                                                                 Date 
                                                                                                                                               
Print Full Name                                        Phone Number                                  Email Address 

NOTARY PUBLIC 
Subscribed and sworn before me this                      day                                                         (SEAL)  
of                            ,                .
                                                                                                                                   
Notary Public                                                                             My Commission Expires                                
If you have any questions regarding this affidavit, please call Customer Service at (312)747-4747.  
Note: If you are purchasing a business in the City of Chicago, you are required per section 3-4-140 of the Uniform 
Revenue Procedures Ordinance to file a Bulk Sales Notification. 
                                                                                                    
   Email completed document to:                                                                     
   RevenueDatabase@cityofchicago.org                                                                                 Authorized Use Only 
   Or mail to:                                                                                      
   Chicago Department of Finance/Database Management Unit                                                            Date Received:  _________________ 
   2 N. La Salle Street, Suite 1310                                                                                  Processed by:    _________________ 
     Chicago, IL 60602                                                                                               Date Processed: _________________