Taxpayer ID Number~2.docx
DOCX document 30 KB Posted
- Solicitation number
- 27-494DOT-FINAD-B-53601
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) certification form for the State of Illinois, required for vendors and contractors conducting business with state agencies. The form serves as documentation that the submitting entity has provided accurate taxpayer identification information and certifies compliance with backup withholding requirements under federal tax law. The form accommodates various business structures including individuals, sole proprietors, partnerships, corporations, limited liability companies, and tax-exempt entities, with specific instructions for each classification regarding the submission of taxpayer identification numbers and supporting documentation such as IRS acceptance letters for corporations.
The form requires completion of entity name, business name, taxpayer identification number (either Social Security Number or Employer Identification Number), selection of legal status, and signature by an authorized representative with date. Applicants must certify they are either exempt from backup withholding, have not been notified of backup withholding status by the Internal Revenue Service, or have been notified they are no longer subject to withholding, and must confirm U.S. person status. This documentation is prerequisite for participating in Illinois state and local contract opportunities, including procurement activities such as the Dynamic Shear Rheometer equipment acquisition for the Illinois Department of Transportation Materials Bureau.
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Other files
| File | Type | Posted |
|---|---|---|
| standard-illinois-certifications-v-26-2~15.pdf | ||
| Vendor Quote~35.pdf | ||
| standard-terms-and-conditions23.2~44.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 | |_| 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 .