ipg active registered vendor disclosure formerly forms b~10.docx

STATE OF ILLINOIS

TAXPAYER IDENTIFICATION NUMBER

BidBuy Reference #: Click here to enter text. Procurement/Contract #: Click here to enter text.

** STOP and READ THIS ** You may only submit this form if you have an ACTIVE (unexpired and approved) registration in the Illinois Procurement Gateway.

This IPG Active Registered Vendor Disclosure may be used when responding to an Invitation for Bid (IFB) or a Request for Proposal (RFP) if the vendor is registered in the Illinois Procurement Gateway (IPG) and has an active State of Illinois Vendor Registration Number. The IPG assigns each vendor a unique State of Illinois Vendor Registration Number and expiration date upon the Chief Procurement Office’s acceptance of the vendor’s IPG application.

If a vendor does not have an active State of Illinois Vendor Registration Number, then the vendor must complete and submit Vendor Disclosure (formerly named Forms A) with their response. Failure to do so may render the submission non-responsive and result in disqualification.

Please read this entire section and provide the requested information as applicable. All parts in the IPG Active Registered Vendor Disclosure must be completed in full and submitted along with the vendor’s bid, offer, or response.

1. Certification of Illinois Procurement Gateway Registration My business has an active State of Illinois Vendor Registration Number.

To ensure that you have an active registration in the IPG, search for your business name in the IPG Registered Vendor Directory. If your company does not appear in the search results, then you do not have an active IPG registration.

State of Illinois Vendor Registration Number: Click here to enter text.

IPG Expiration Date: Click here to enter text.

2. Certification Timely to this Solicitation or Contract Vendor certifies it is not barred from having a contract with the State based upon violating the prohibitions related to either submitting/writing specifications or providing assistance to an employee of the State of Illinois by reviewing, drafting, directing, or preparing any invitation for bids, a request for proposal, or request of information, or similar assistance (except as part of a public request for such information). 30 ILCS 500/50-10.5(e). |_| Yes |_| No

3. Disclosure of Lobbyist or Agent (Complete only if bid, offer, or contract has an annual value over $100,000) Is your company or parent entity(ies) represented by or do you or your parent entity(ies) employ a lobbyist required to register under the Lobbyist Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or an agent who has communicated, is communicating, or may communicate with any State officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name and address below. |_| Yes |_| No If yes, please identify each lobbyist and agent, including the name and address below. If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist’s information. Additional rows may be inserted into the table or an attachment may be provided if needed.

Describe all costs/fees/compensation/reimbursements related to the assistance provided by each representative lobbyist or other agent to obtain this Agency contract: Click here to enter text.

4. Disclosure of Current and Pending Contracts Complete only if: (a) your business is for-profit and (b) the bid, offer, or contract has an annual value over $100,000. Do not complete if you are a not-for-profit entity.

|_| Yes |_| No. Do you have any contracts, pending contracts, bids, proposals, subcontracts, leases or other ongoing procurement relationships with units of State of Illinois government?

If “Yes”, please specify below. Additional rows may be inserted into the table or an attachment in the same format may be provided if needed.

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5. Signature As of the date signed below, I certify that:

· My business’ information and the certifications made in the Illinois Procurement Gateway are truthful and accurate.

· The certifications and disclosures made in this IPG Active Registered Vendor Disclosure are truthful and accurate.

This IPG Active Registered Vendor Disclosure is signed by an authorized officer or employee on behalf of the bidder, offeror, or vendor pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code, and the affirmation of the accuracy of the financial disclosures is made under penalty of perjury.

This disclosure information is submitted on behalf of:

Signature: Date: Click here to enter text.

Printed Name: Click here to enter text.

STATE OF ILLINOIS

IPG ACTIVE REGISTERED VENDOR DISCLOSURE

(formerly named FORMS B) Title: Click here to enter text.

State of Illinois Chief Procurement Office for General Services 3 IPG Active Registered Vendor Disclosure V.23.1 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.