Form Il-W-5 - Cert Il Residence - Iowa Wesleyan University
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Illinois Department of Revenue
IL-W-5
Certificate of Residence in Illinois
Must I complete this form?
No further reporting is required under these sections once you complete
this certification. Your completed and signed form must be filed with the
You must complete this form if you are an Illinois resident who performs
employing withholding agent.
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 con-
Note: Instead of completing this form, you may file a certificate of in-state
ducted entirely in Illinois and the income earned is taxable under Section
residence on any invoice, billing statement, or contest application submit-
1405.3 of the Illinois Income Tax Act.
ted to the withholding agent.
Part 1: Recipient’s information
Part 2: Withholding agent’s information
(completed by recipient)
___ ___ ___ - ___ ___ - ___ ___ ___ ___
(completed by withholding agent)
Social Security number
___ ___ - ___ ___ ___ ___ ___ ___ ___
0680332
42
_______________________________________________________
Federal employer identification number
Recipient’s name
______________________________________________________
Iowa Wesleyan University
_______________________________________________________
Withholding agent’s name
Street
City
State
ZIP
601 N. Main St
Mount Pleasant
IA
52641
______________________________________________________
I declare under penalties of perjury that I am a resident of the state of Illinois.
Street
City
State
ZIP
_______________________________________________________
Recipient’s signature
Date
This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required.
IL-W-5 (R-12/03)
Failure to provide information may result in this form not being processed and may result in a penalty.
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