Taxpayer Identification Number Form~2.pdf
PDF 112 KB Posted
- Attached to
- AGR-ISF-Video Gaming Services
- Solicitation number
- 24-406AGR-FRHRS-B-40619
- Issued by
- St. Clair County, Illinois
About this file
This document is a Taxpayer Identification Number Form from the State of Illinois Chief Procurement Office. The form requires the provider to submit their name, business name, and taxpayer identification number, either a Social Security Number or an Employer Identification Number. The provider must also indicate their legal status, such as an individual, sole proprietor, partnership, corporation, or other entity type.
This form is related to a state and local contract opportunity from the Illinois Department of Agriculture to provide Electronic Video Gaming Services at the Illinois State Fair. The contract requires the selected vendor to provide these services pursuant to the details outlined in the attachments. The response to this solicitation must be submitted electronically; paper responses will not be accepted.
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Other files
| File | Type | Posted |
|---|---|---|
| Standard Terms and Conditions v.23.2~1.docx | DOCX document | |
| Notice of Award-ISF-Gaming~1.pdf | ||
| IL State Board of Elections Registration Manual~1.pdf | ||
| IFB-ISF-Gaming Final~1.docx | DOCX document | |
| IPG Registration Instructions~1.docx | DOCX document | |
| TIN Form v23.2.docx | DOCX document | |
| standard-illinois-certifications-v.23.1~3.docx | DOCX document | |
| attachment-notice-of-electronic-submission-only-v-23-1~2.pdf | ||
| Vendor Disclosure formerly Forms A v.23.3~2 (1).docx | DOCX document | |
| IPG Active Registered Vendor Disclosure -formerly Forms B v.23.1~3 (2).docx | DOCX document | |
| cpo-notice-2023.12-electronic-submission~1.pdf | ||
| Amendment 1-ISF-Video Gaming Services.docx | DOCX document |
Show all 12
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
State of Illinois Chief Procurement Office General Services 1 Taxpayer Identification Number V.15.2
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:
File details come from the government source that posted it. Updated .