Blank TIN Form~30.docx
DOCX document 30 KB Posted
- Attached to
- Pest Control A8274 Pawnee
- Solicitation number
- 27-416CMS-BOPM4-B-53703
- Issued by
- Sangamon County, Illinois
About this file
This is a Taxpayer Identification Number (TIN) form for the State of Illinois, associated with a Pest Control A8274 procurement opportunity in Pawnee, Illinois. The form serves as a certification document for contractors bidding on state and local contracts, requiring entities to provide their correct taxpayer identification information and confirm their compliance with federal backup withholding requirements. The form accommodates various legal entity types, including individuals, sole proprietors, partnerships, corporations, limited liability companies, and tax-exempt organizations, with specific instructions for each classification regarding name entry and identification number submission.
This TIN form is a mandatory documentation requirement for vendors participating in the Small Business Set Aside Program procurement for pest control services at site A8274, located at Washington Street and 13th Street in Pawnee, Illinois 62558. Bidders must complete the form with accurate taxpayer identification information and certify their status as a U.S. person or entity not subject to backup withholding, with an authorized representative signature and date required. The form specifically notes that for corporations providing or billing medical and/or health care services, an IRS acceptance letter must be attached, and entities must select their appropriate tax classification to ensure compliance with state procurement requirements.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Pre-Bid Walk Through Notice-Mandatory B-53703.docx | DOCX document | |
| Contract B-53703 Pest Control A8274 Pawnee.docx | DOCX document | |
| Standard-Illinois-Certifications-v-26-2~26.pdf | ||
| Pest Control - Line Item 7 Pricing Instructions B-53703.docx | DOCX document |
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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 .