Tax Compliance Form

TAX COMPLIANCE

INSTRUCTIONS TO SUPPLIERS

Please complete the following information:

· Supplier’s Name:

· Physical Location Address:

· Federal Identification Number (FEI):

· Have you ever been registered in the State of Georgia?

· If so, please provide the following information, if applicable:

· State Taxpayer Identification Number (STI):

· Sales and Use Tax Number:

· Withholding Tax Number:

· What type of service will you perform?

· Will you sell any tangible personal property or goods?

· Supplier’s Affiliate’s Name:

· FEI:

· STI:

· Sales and Use Tax Number:

· Withholding Tax Number:

If there is more than one affiliate, please attach a separate sheet listing the information above.

· Person responsible for handling supplier’s tax issues (such as the CFO, the company tax officer, etc.):

· Name:

· Telephone Number:

· E-mail Address:

NOTICE TO SUPPLIER:

In the event the supplier is considered for contract award, the information provided in the form will be submitted by the State Entity to the Georgia Department of Revenue (“DOR”) for a determination as to whether the supplier is a “prohibited source” (as defined by O.C.G.A. §50-5-82) or whether there are any other outstanding tax issues. MISSING, INCOMPLETE, OR ERRONEOUS DATA MAY DELAY OR PROHIBIT VERIFICATION OF YOUR ELIGIBILITY FOR CONTRACT AWARD. NO PROHIBITED SOURCE MAY RECEIVE CONTRACT AWARD; THEREFORE, YOU ARE STRONGLY ENCOURAGED TO CHECK YOUR TAX STATUS NOW AND RESOLVE ANY OUTSTANDING TAX LIABILITIES AND/OR MISSING TAX RETURNS.

STATE ENTITY: Please submit this form via email to DOR at tsd-state-contractors@dor.ga.gov for processing in accordance with the Georgia Procurement Manual.

Revised: 12/22/2010

SPD-SP045

An Equal Opportunity Employer