CITY OF CHICAGO 
                                                  DEPARTMENT OF FINANCE 
                                                AFFIDAVIT FOR FINAL TAXABLE PERIOD 

I, __________________________________, as authorized representative, holding the title of 
  (Business Representative) 
__________________________________ hereby attest that  __________________________ 
              (Title)                                                                               (Business Name) 
located at__________________________________________________________ and having  
           (Street Address)                          (City)                               (State)  (Zip code) 
Chicago Department of Finance tax account number ____________-_         ___ is no longer  
                                                              (IRIS No.)                           (Site No.) 
required  to remit the City of Chicago _____________________________.  I hereby request that  
                                                            (Tax Type) 
the tax type stated above be deactivated as of  ___________________* for the following reason(s):                         
                                                          (Date Last Subject to Tax)   
NOTE:  YOU  MUST  SPECIFY  WHY  YOUR  BUSINESS  ACTIVITY  IS  NO  LONGER 
REQUIRED TO COLLECT AND/OR REMIT THE TAX CODE LISTED ABOVE. 
                                                                                                                          
*The entity filing this affidavit is still required to file a tax return for this tax code to report the taxable activity and/or 
taxes paid (even erroneously) for the final tax period.  If your business is still in operation, file the return on or before 
the August 15 following the date last subject to tax.  If your business is closed, file a return for this tax code on or 
before 45 days after your business ceased operations.  Please complete a Business Change Form if you are closing or 
selling your business.  If you are selling your business, please file a Bulk Sales Notice.          

I further attest that I have the knowledge and authority to make the above statements.  Should the 
facts above change at any time, we will request to reactivate this account immediately. 

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 
of                           ,                .                                                      (SEAL) 
 
_____________________________                                                                                                                                             
Notary Public                                                                             My Commission Expires 
                                                                                                                          
If you have any questions regarding this affidavit, please call Customer Service at (312)747-4747.  
If your business has ceased operations or is being sold, please complete a Business Change Form. 
If your business is being sold please also complete a Bulk Sales Notice. 
                                                               
  Email completed document to 
                                                               
  RevenueDatabase@cityofchicago.org                                                               Authorized Use Only 
  Or mail Return To: 
  Chicago Department of Finance/Database Management Unit                                          Date Received: _________________ 
  333 South State Street, Suite 300                                                               Processed by: _________________ 
     Chicago, IL 60604-3977                                                                       Date Processed: _________________