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       Illinois Department of Revenue

       IDR-916  Signature Declaration

Step 1: Provide the following information

       Name as shown on return                                            Identifi cation number (Social Security, federal employer 
                                                                          identifi cation, or Illinois business tax/account ID number)

       Address                                                            Account period ending
                                                                          Tax type (Please check one.)
       City, State, Zip 
                                                                           Individual Income Tax       Withholding Income Tax
       (         )
                                                                           Business Income Tax          Sales Tax
       Daytime telephone number

Step 2: Complete the “Signature Declaration” 

You must sign a “Signature Declaration” and return it to us if we sent you a notice that you fi led an original return, an 
amended return, or any other document that was required to be verifi ed under penalties of perjury, and you did not sign it. 

If we requested your signature, you may use the “Signature Declaration” below to provide it. Please sign and date the 
“Signature Declaration,” and return it to us at the address listed below. 
If you do not provide us with a properly completed and signed “Signature Declaration,” you may be assessed penalties and 
interest. For more information on penalties and interest, see Publication 103, Penalties and Interest for Illinois Taxes.

                                          Signature Declaration 
Under penalties of perjury, I declare that I did examine the document I fi led and that it, including any accompanying 
schedules and statements, was to the best of my knowledge and belief true, correct, and complete. I request that this 
document become a permanent part of my return.

 Your signature                                 Date        Spouse’s signature                                   Date
                                                            (required only for a joint Individual Income Tax return)

                                             Reset          Print
Illinois Department of Revenue
Clerical Support
PO Box 19084
Springfi eld, IL 62794-9084

         If we requested your signature, please sign the “Signature Declaration” and return this page.
                  Do not use this form unless we requested a “Signature Declaration” from you. 

IDR-916 (R-6/08) 
IL-492-4349