Financial Disclosure Form - City Of Chicago printable pdf download

Financial Disclosure Form - City Of Chicago

FDF

FINANCIAL DISCLOSURE FORM

FORM REQUIRED: Used to document the source of all money invested or spent to fund a new establishment, expand an existing

establishment, or buy an existing business, when the business holds one of the following licenses: Liquor (1470, 1473, 1474, 1475, 1478,

1479, 1480, 1481), Amusement (1046, 1050, 1056), Hotel (1370), Massage Establishment (1524), or Day Care (1584, 1585, 1586, 1587)

INSTRUCTIONS: Complete the 4 parts below, being sure to follow all printed instructions carefully. If a section does not apply, mark it

“N/A”. If more room is needed to complete any of the following sections, include an attachment. This form must be signed and notarized

in Part 4 by an owner or officer listed with the Department of Business Affairs & Consumer Protection.

PART 1

INFORMATION

PROVIDE THE FOLLOWING INFORMATION ABOUT THE LEGAL ENTITY APPLYING FOR THE LICENSE(S)

Account # (Business Affairs)

FEIN # (IRS)

IBT # (IL Dept. Rev.)

IL State File # (IL Sec. State)

Legal Name of Applicant Entity

“Doing Business as Name” of establishment

First Name of Primary Business Contact

Middle Name

Last Name

Home Street Address of Primary Business Contact

Suite/Apt.

City

State

Zip code

Home Phone

Work Phone

Cellular Phone

Email Address

(

)

(

)

(

)

PART 2

EXPENSES

ITEMIZE ALL EXPENSES FOR THE FUNDING OF THE BUSINESS OR OWNERSHIP CHANGE AT THIS LOCATION

Description of Expenses (start-up, expansion, and/or business purchase costs only: construction, renovation, stock purchase, inventory, etc.)

Amount of Expense

Total Expenses:

(Should be equal to or less than Total Business Financing amount on page 3)

Financial Disclosure Form - City Of Chicago