Illinois Certificate of Residence in Illinois

Certificate of Residence in Illinois
IL-W-5, Certificate of Residence in Illinois
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.

	

	

Illinois Department of Revenue

IL-W-5 Certificate of Residence in Illinois

Must I complete this form?

You must complete this form if you are an Illinois resident who performs
personal services and the income is taxable under Section 1405.2 of the
Illinois Income Tax Act, or receives prizes or awards from a contest conducted entirely in Illinois and the income earned is taxable under Section
1405.3 of the Illinois Income Tax Act.

No further reporting is required under these sections once you complete
this certification. Your completed and signed form must be filed with the
employing withholding agent.
Note:  Instead of completing this form, you may file a certificate of in-state
residence on any invoice, billing statement, or contest application submitted to the withholding agent.

Part 1:	 Recipient’s information (completed by recipient)

Part 2:	 Withholding agent’s information

___ ___ ___ - ___ ___ - ___ ___ ___ ___

(completed by withholding agent)

Social Security number

	_______________________________________________________
Recipient’s name

_______________________________________________________
Street	

City	

State

ZIP	

I declare under penalties of perjury that I am a resident of the state of Illinois.

___ ___ - ___ ___ ___ ___ ___ ___ ___
Federal employer identification number

______________________________________________________
Withholding agent’s name

______________________________________________________
Street	

City	

State

ZIP	

_______________________________________________________
Recipient’s signature	

Date

IL-W-5 (R-12/03)

Reset

This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
Failure to provide information may result in this form not being processed and may result in a penalty.

Print