Taxpayer Identification Page~5.docx
DOCX document 20 KB Posted
- Attached to
- QM-Fusees/Roadflares-CB
- Solicitation number
- 26-493ISP-ADMIN-B-50162
- Issued by
- Illinois
About this file
This document is a Taxpayer Identification Number (TIN) form issued by the State of Illinois Chief Procurement Office for General Services. The form requires bidders and contractors to provide accurate taxpayer identification information and certify their tax compliance status. Respondents must enter their legal name, business name if applicable, and either a Social Security Number or Employer Identification Number depending on their business structure. The form includes checkboxes for various legal entity types, including individual, sole proprietor, partnership, corporation, limited liability company, and tax-exempt organizations, among others. Bidders must also certify that their provided TIN is correct, that they are not subject to backup withholding unless previously notified by the IRS, and that they are a U.S. person or U.S. resident alien. An authorized representative must sign and date the completed form.
The document serves as a standard tax compliance verification requirement for State of Illinois contracting purposes. Sole proprietors and single-member LLCs must provide owner information along with business identification, while partnerships, corporations, and other entities must provide the entity's EIN and appropriate documentation such as IRS acceptance letters for corporations. The form does not contain specific pricing terms, contract amounts, or funding information, as it functions purely as a taxpayer identification and certification document required during the procurement process.
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Other files
| File | Type | Posted |
|---|---|---|
| Fusee Specifications 12-1.docx | DOCX document | |
| Standard Illinois Certifications v.26.2~13.pdf | ||
| standard-terms-and-conditions 23.2~84.pdf | ||
| standard terms and conditions~58.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: ___________________________ State of Illinois Chief Procurement Office for General Services Contract V.23.2
File details come from the government source that posted it. Updated .