2-WH-5 Public Works Contract Report.pdf

Idaho State Tax Commission

WH-5 Public Works Contract Report Idaho Code sections 54-1904A and 63-3624(g) require all public works contracts to be reported to the Tax Commission. This form must be filed with the Tax Commission within 30 days after a contract is awarded.

Project Dates Scheduled project start date: _______________________ Completion date: ____________________________

If the following information is not available at this time, please indicate date it will be: ____________________________

All Subcontractors

EFO00168 04-28-11

Contract awarded by (public body and address)

Contract awarded to (contractor’s name and address)

State of incorporation Federal Employer Identification Number (EIN) Date qualifed to do business in Idaho

Business operates as Public Works contractor license number

Sole proprietor’s Social Security number Idaho sales/use tax permit number Idaho withholding tax permit number

Awarding agency project number Amount of contract

Description and location of work to be performed

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Sole proprietorship Partnership Corporation LLC

Ref. No. (State use only)

EFO00168p2 04-28-11

All Subcontractors (Continued)

Suppliers Use the space below to report major suppliers of materials and supplies; items removed from inventory; equipment purchased, rented, or leased for use in project; materials provided by government agency. Please indicate how sales or use tax was paid.

* If tax was not paid to suppliers but was or will be reported as “items subject to use tax” under your permit number, indicate period of return on which payment was or will be reported: _______________________________________ If tax was paid to a state other than Idaho, name state next to “total value” box(es) above. If tax is due and has not previously been reported, attach payment to this form. If you need more room, please photocopy this page.

SIGN

HERE

File with the Idaho State Tax Commission, PO Box 36, Boise ID 83722-2210.

For more information, call (208) 334-7618 • Fax: (208) 332-6619 • E-mail: Contractdesk@tax.idaho.gov.

Authorized signature Print name Phone number Date

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Name Federal EIN

Address Public works contractor number

City, State, ZIP Amount of subcontract

Description of work

Name Federal EIN Total value

Address Materials and equipment purchased and used

City, State, ZIP Phone

Name Federal EIN Total value

Address Materials and equipment purchased and used

City, State, ZIP Phone

Name Federal EIN Total value

Address Materials and equipment purchased and used

City, State, ZIP Phone

Name Federal EIN Total value

Address Materials and equipment purchased and used

City, State, ZIP Phone

Tax paid to supplier Tax paid to state* No tax paid

Tax paid to supplier Tax paid to state* No tax paid

Tax paid to supplier Tax paid to state* No tax paid

Tax paid to supplier Tax paid to state* No tax paid