Taxpayer ID Number form 15.2-BLANK.docx
DOCX document 18 KB Posted
- Contract number
- 26-444DHS-MIS44-P-92497
- Issued by
- Illinois
About this file
This is a blank Taxpayer Identification Number (TIN) form issued by the State of Illinois. The document serves as a template for collecting taxpayer identification information from vendors, contractors, or other entities conducting business with the state. It is designed to comply with federal backup withholding requirements and verify the tax status of contracting parties.
The form requires completion of the taxpayer's legal name, business name (if applicable), and either a Social Security Number or Employer Identification Number depending on the entity type. The document includes checkboxes for multiple legal entity classifications, including individuals, sole proprietors, partnerships, corporations, limited liability companies, and tax-exempt organizations. For corporations providing medical or health care services, respondents must specify their tax classification as a disregarded entity, C corporation, or partnership. The form must be signed and dated by an authorized representative and is used to certify that the provided identification number is correct and that the entity is not subject to backup withholding unless otherwise notified by the Internal Revenue Service.
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| standard-illinois-certifications-v-26-2-BLANK.pdf | ||
| IT Terms and Conditions v.26.1 w DHS Provisions.pdf |
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
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 | |_| 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 .