State of Illinois Taxpayer ID Page~1.docx
DOCX document 16 KB Posted
- Attached to
- IDJJ Fingerprint System Monarch
- Solicitation number
- 26-425DJJ-AFTER-B-49425
- Issued by
- Livingston County, Illinois
About this file
This is a State of Illinois Taxpayer Identification Number form used for vendor registration and tax compliance purposes. The form requires bidders and contractors to provide their correct taxpayer identification information and certify their compliance with Internal Revenue Service backup withholding requirements. Respondents must supply their legal name, business name if applicable, and either a Social Security Number for individuals or an Employer Identification Number for entities. The form requires selection of legal status from multiple categories, including individual, sole proprietor, partnership, corporation, limited liability company, and tax-exempt organization, with additional specifications for healthcare service providers and pharmacy entities. For corporations, the form requires attachment of IRS acceptance letters (CP261 or CP277). An authorized representative must sign the form with the current date.
This form serves as a prerequisite document for contract bidding with the State of Illinois and establishes the vendor's tax classification and withholding status. Completion of this form is mandatory for all potential contractors regardless of contract value or scope. The form does not contain pricing information, set-asides, funding amounts, or contract terms, as it functions solely as a tax identification and compliance verification document required during the vendor registration process.
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
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):
| |_| 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 | |_| D = disregarded entity | ||||
| medical and/or health care services | |_| C = corporation | ||||
| |_| P = partnership |
Signature of Authorized Representative:
Date: Click here to enter a date
File details come from the government source that posted it. Updated .