certification-of-no-change-for-contract-renewal-v-23.1.docx

STATE OF ILLINOIS

TAXPAYER IDENTIFICATION NUMBER

When renewing a State contract, if there has been a change in the information originally provided and accepted (by the State at the time of contract execution) on either the Financial Disclosures and Conflicts of Interest form or the Standard Illinois Certifications form, then vendors, parent entity(ies), and subcontractors must complete and re-submit the appropriate form for which a change occurred.

However, if the information originally submitted on either of the forms has not changed, then this form may be used to certify that there has been no change.

This certification is submitted for:

STATE OF ILLINOIS

CERTIFICATION OF NO CHANGE FOR CONTRACT RENEWAL

State of Illinois Chief Procurement Office for General Services 1 Certification of No Change for Contract Renewal V.23.1

|_| Vendor |_| Vendor’s Parent Entity(ies) (100% ownership) |_| Subcontractor(s) >$100,000 |_| Subcontractor’s Parent Entity(ies) (100% ownership) > $100,000

This disclosure is signed and made under penalty of perjury by an authorized officer or employee of the company pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code.

Authorized Signature:

Printed Name: Click here to enter text.

Title: Click here to enter text.

Email Address: Click here to enter text.

Phone Number: Click here to enter text.

Date: Click here to enter a date.

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: Click here to enter text.

Business Name: Click here to enter text.

Taxpayer Identification Number:

Social Security Number: Click here to enter text.

or Employer Identification Number : Click here to enter text.

Legal Status (check one):

Signature of Authorized Representative:

Date: Click here to enter a date

State of Illinois Chief Procurement Office for General Services Taxpayer Identification Number V.23.1