2022 Investor Claimant Application

ILLINOIS ANGEL INVESTMENT TAX CREDIT PROGRAM

Investor Claimant Application 2022
CLAIMANT INFORMATION
Type of Application *

Initial Application Appeal
Reason for Appeal
Please select the option that best fits the applicant (investor). *

Trust Individual Limited Liability Company Corporation Partnership
Claimant's Name

First Name Last Name
Business Name
Trust Name
Are you using an EIN or SSN?

EIN SSN
EIN
Social Security Number
Masked SSN
Email *
example@example.com
Phone Number *
Address *

Street Address

Street Address Line 2

City State

Zip Code
CONTACT INFORMATION

Contact Info for All Correspondence (if different than claimant listed above)
Is contact information below the same as above?

Yes
Please update contact information if you would like correspondence to be provided to another contact.
Name *

First Name Last Name
Phone Number *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
INVESTMENT INFORMATION
QNBV Name *
Name of QNBV you invested into.
QNBV Number *
This can be received by the QNBV you invested in. It will be a 3-digit number followed by a letter which can be found on their QNBV certificate they received for the program.
Investment Amount *
NOTE: Exact amount transferred to business is needed to process application. If this does not match the proof of funds transferred amount, this will cause a delay with your application.
Date of Investment *

Month Day Year
Enter the date the funds were initially transferred.
Do you AND Related Members have a direct or indirect ownership interest of at least 51% - in aggregate - of the QNBV? *"Related Member" is defined at https://bit.ly/2TDFCIu *

Yes No
If you and Related Members have a direct or indirect ownership interest of at least 51% of the QNBV, please provide details to explain (including, but not limited to, how members are related and a breakdown of ownership percentages).
Percent ownership interest held by the applicant only. *
(If 40.5%, enter "40.5" - not ".405".
Will this investment remain in the QNBV for a minimum of 3 years? *

Yes No
Is this an equity investment? (If this is a SAFE or Convertible Note, please select "No" and provide detail in the box that drops down.) *

Yes No
Please share more information about the type of investment.
Please note: SAFEs and Convertible Notes can be approved as long a they include a mandatory clause and meet all other eligibility criteria.
"Angel Investment" means money (or its equivalent) given to a qualified new business venture, at a risk of loss, in consideration for an equity interest of the qualified new business venture. For the purpose of this definition, an investment is at a risk of loss if its repayment depends entirely upon the success of the business operation of the Qualified New Business Venture.
Is your investment eligible per the program definition above? *

Yes No
REQUIRED ATTACHMENTS
Please provide outgoing proof of funds. *

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This can be a check, screenshot of bank statement, email to banker for transfers, etc... This documentation needs to include the investor's name, date and amount of the investment. **Pending transactions will not be accepted.** Cancel of
Please provide incoming proof of funds. *

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Please obtain a screenshot from the QNBV's account showing the name of the business, date and amount of investment. **Pending transactions will not be accepted. ** Cancel of
The completed executed legal document detailing the investment *

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If this is a SAFE or Convertible Note, you will need to be sure the 3 year conversion is included. Cancel of
Please complete the "Trust Identification and Disclosure Form" found at the very bottom of the Angel Tax Credit Program website and upload here.

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CERTIFICATION
Authorized Executive Officer/Individual:
Name *

First Name Last Name
Title (if applicable) *
Date *

Month Day Year
Date
Signature *

Clear
NOTE: You can print your responses for your own records, but you must select "Preview Answers" below and then "Submit" to complete the submission process. You will see a confirmation page appear and receive a confirmation email.
Please download the Certification Form from here, then attach the signed form using the button below.
Certification Form:

Upload File

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The Department of Commerce and Economic Opportunity (DCEO) is committed to protecting the privacy of its vendors, grantees and beneficiaries of programs and services. At times, DCEO will request social security numbers (SSNs) or other personal identifying information. Federal and state laws, rules and regulations require the collection of this information for certain purposes relating to employment and/or payments for goods and services, including, but not limited to, grants. DCEO also collects confidential information for oversight and monitoring purposes.

Furnishing personal identity information, such as a social security number, is voluntary; however, failure to provide required personal identity information may prevent an individual or organization from using the services/benefits provided by DCEO as a result of state or federal laws, rules and regulations.
Should be Empty:

CLAIMANT INFORMATION

CONTACT INFORMATION

INVESTMENT INFORMATION

REQUIRED ATTACHMENTS

CERTIFICATION