Tax ID Form~3.pdf
PDF 92 KB Posted
- Contract number
- 26-588IEMA-OPERA-P-95358
- Issued by
- Illinois
About this file
This is a State of Illinois Taxpayer Identification Number (TIN) form administered by the State of Illinois Chief Procurement Office for General Services. It serves as an IPG Active Registered Vendor Disclosure document (version 26.1) and is used to verify vendor identification information for state procurement purposes.
The form requires vendors to provide their correct taxpayer identification number, certify their U.S. person status, and confirm they are not subject to backup withholding by the Internal Revenue Service. Vendors must supply their name, business name, and either a Social Security Number or Employer Identification Number depending on their legal entity status, which includes options for individuals, sole proprietors, partnerships, corporations, limited liability companies, and specialized entities such as legal services corporations, tax-exempt organizations, and pharmacy operations. An authorized representative must sign and date the form to certify the accuracy of the information provided.
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
State of Illinois Chief Procurement Office for General Services 4 IPG Active Registered Vendor Disclosure V.26.1
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):
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.
| ADPF35.tmp |
| 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 tabl... |
| 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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