Tax ID page_26 1~13.pdf
PDF 70 KB Posted
- Contract number
- 26-493ISP-FOREN-P-97882
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) Certification and Disclosure form issued by the State of Illinois Chief Procurement Office General Services. The form serves as a standardized document for use in state and local contract awards and procurement processes within Illinois.
The form requires submission of taxpayer identification information and certifications regarding backup withholding status and U.S. person eligibility. Respondents must provide 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, tax-exempt entities, and specialized entities such as legal services corporations and pharmacies. The form requires certification that the provided identification number is correct, that the respondent is not subject to backup withholding, and that the respondent is a U.S. person. An authorized representative must sign and date the completed form. This certification document is typically required as part of contract execution and vendor registration processes for state procurement in Illinois.
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
State of Illinois Chief Procurement Office General Services 3 FORMS B Certifications and Disclosures V.18.1
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.
File details come from the government source that posted it. Updated .