Illinois Department of Revenue
Request for Tax Clearance
Note: We will attempt to process and mail your clearance to you within 10 working days.
Step 1: Identify yourself or your business
1
_______________________________________
9
Name
Date business activity was initiated in Illinois _____/_____/_____
Month
Day
Year
2
_______________________________________ 10
DBA
Do you make retail sales in Illinois?
yes
no
Doing business as
3
11
Address _________________________________________
Do you maintain an office in Illinois?
yes
no
Number and street or post office box
_________________________________ 12
City, state, ZIP
Do you have employees in Illinois?
yes
no
(
)
-
4
13
Phone no. _______________________________________
If you want this clearance to be sent to a third party, please
Area code
write the party’s name and address below.
5
FEIN ___________________________________________
Federal employer identification number
6
____________________________________________
ROT no.
_____________________________________
Name
7
Social Security no.
__ __ __ - __ __ - __ __ __ __
Address ______________________________________________
Number and street or post office box
8
______________________________________
Excise tax no.
_________________________________
City, state, ZIP
Step 2: Identify the taxes for which you are requesting clearance
Check all appropriate boxes.
1
5
Automobile renting tax
Individual income tax
2
6
Business income tax
Retailer’s occupation tax (sales and use taxes)
3
7
Excise tax (specify) ____________________________
Withholding tax
4
Hotel/motel tax
Step 3: Tell us why you are requesting clearance
Check all appropriate boxes.
1
4
Real estate transaction
Sale of business assets (return this letter and
2
Bank closing
Form NUC-542-A to that address shown on that form)
3
5
Required by a state other than Illinois
Other (specify) _____________________________________
Step 4: Sign below
____________________________ _____/_____/_____
_____________________________________________________
Signature
Month
Day
Year
Title (for example, president, owner, partner, individual)
Mail to: ILLINOIS DEPARTMENT OF REVENUE
or fax: 217 782-4217
TAXPAYER ASSISTANCE DIVISION (3-253)
PO BOX 19001
SPRINGFIELD IL 62794-9001
Official Use Only
This is your approved tax clearance for the item(s) identified in Step 2, Box(es)__________________________________,as you requested.
Note: This clearance does not preclude assessment for any liability for pending, current, or future taxes or liabilities that may be
established by present or future audits conducted by the department. Also, this clearance does not include the Corporate Franchise Tax
(see below).
____________________________ _____/_____/_____
Month
Day
Year
Public Service Administrator
Taxpayer Assistance Division
Note: The Corporate Franchise Tax is administered by the Office of the Secretary of State. If you want a Certificate of Good Standing, send
your request with a check in the amount of $5 to: Office of the Secretary of State, Department of Business Services, Certified Copy Section,
Springfield, IL 62756. If you have questions about the Corporate Franchise Tax, please call 217 782-6875.
This form is authorized as outlined by the Retailers’ Occupation Tax Act and Income Tax Act. Disclosure of this information is REQUIRED. Failure
SOY-BASE INK
ITR-1 (R-9/97)
to provide information could result in the denial of your request. This form has been approved by the Forms Management Center.
IL-492-2867
RECYCLED PAPER