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)                    (Zipcode)
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 
  or Fax to: (312) 747-1890 attn: Database Unit
  Or Mail To:                                                                                     Authorized use Only
  Chicago Department of Finance                                                          Date Received: _________________
  Database Management Unit                                                               Processed by: _________________
  333 South State Street, Suite 300                                                      Date Processed: _________________
  Chicago, IL 60604-3977

R 12/1/2011