Taxpayer ID Number form 23.2~1.docx
DOCX document 45 KB Posted
- Attached to
- 27-Micromedex Subscr SP SS
- Solicitation number
- 27-444DHS-MIS44-B-53404
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) form utilized by the State of Illinois, specifically the Chief Procurement Office under General Services, for vendor registration and compliance purposes related to state contract opportunities. The form is designed to capture essential identification information from vendors seeking to conduct business with the State of Illinois, including individuals, sole proprietors, partnerships, corporations, limited liability companies, and other entity types. The form requires vendors to provide their legal name, business name if applicable, and either a Social Security Number or Employer Identification Number, along with certification that the provided taxpayer identification number is correct and that the vendor is not subject to backup withholding by the Internal Revenue Service.
The form accommodates multiple legal entity classifications through checkbox options, including individuals, sole proprietors, partnerships, corporations, limited liability companies, governmental entities, tax-exempt organizations, and specialized entities such as pharmacies and legal services corporations. For certain entity types, particularly corporations providing medical and healthcare services, vendors must specify their tax classification as either a C corporation or partnership. The form requires the signature of an authorized representative and the date of execution. This particular form is associated with a State of Illinois small purchase contract opportunity for Micromedex pharmacy software under sole source conditions, indicating its use in the procurement process for specialized vendor qualification and tax compliance verification.
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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 | |_| C = corporation | ||||
| medical and/or health care services | |_| P = partnership |
Signature of Authorized Representative:
Date: Click here to enter a date.
State of Illinois Chief Procurement Office General Services 9 Taxpayer Identification Number V.23.2
File details come from the government source that posted it. Updated .