Blank TIN Form~14.docx
DOCX document 30 KB Posted
- Solicitation number
- 26-444DHS-PROCU-B-50720
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) form for the State of Illinois used in conjunction with an emergency final cost and term reporting submission for mold remediation and testing services at the Mabley Center. The form serves as a certification document for contractors or vendors providing their taxpayer identification information as part of the procurement process. Respondents must provide their legal name, business name, and appropriate tax identification number (either Social Security Number or Employer Identification Number) based on their business entity type. The form requires respondents to certify their correct taxpayer identification status and confirm they are not subject to backup withholding, unless specifically notified otherwise by the Internal Revenue Service.
The form accommodates various business structures including individuals, sole proprietors, partnerships, corporations, limited liability companies, and tax-exempt entities, with specific instructions for each classification regarding name and identification number submission. For corporations providing medical and health care services, respondents must indicate their tax classification and attach relevant IRS acceptance documentation. This TIN form is supporting documentation for the Mabley Center emergency mold remediation and testing project, which is being reported as final cost and term information rather than as an open bidding opportunity.
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Other files
| File | Type | Posted |
|---|---|---|
| Walk-Through Instructions B-50722.docx | DOCX document | |
| Emergency Final Cost and Term - Mabley Mold Emergency B-49263.pdf |
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
I certify that:
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien).
· If you are an individual, enter your name and SSN as it appears on your Social Security Card.
· If you are a sole proprietor, enter the owner’s name on the name line followed by the name of the business and the owner’s SSN or EIN.
· If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s name on the name line and the D/B/A on the business name line and enter the owner’s SSN or EIN.
· If the LLC is a corporation or partnership, enter the entity’s business name and EIN and for corporations, attach IRS acceptance letter (CP261 or CP277).
· For all other entities, enter the name of the entity as used to apply for the entity’s EIN and the EIN.
Name:
Business Name:
Taxpayer Identification Number:
Social Security Number:
or Employer Identification Number:
Legal Status (check one):
| |_| Individual | |_| Governmental | ||||
| |_| Sole Proprietor | |_| Nonresident alien | ||||
| |_| Partnership | |_| Estate or trust | ||||
| |_| Legal Services Corporation | |_| Pharmacy (Non-Corp.) | ||||
| |_| Tax-exempt | |_| Pharmacy/Funeral Home/Cemetery (Corp.) | ||||
| |_| Corporation providing or billing | |_| Limited Liability Company | ||||
| medical and/or health care services | (select applicable tax classification) | ||||
| |_| Corporation NOT providing or billing | |_| C = corporation | ||||
| medical and/or health care services | |_| P = partnership |
Signature of Authorized Representative:
Date: Click here to enter a date.
File details come from the government source that posted it. Updated .