Taxpayer Identification Page~7.docx
DOCX document 27 KB Posted
- Attached to
- IDOC-White Broadcloth 50/50
- Solicitation number
- 26-426DOC-CENTR-B-50263
- Issued by
- Adams County, Illinois
About this file
This is a Taxpayer Identification Number form issued by the State of Illinois Chief Procurement Office for General Services Contract. The form is used to collect and verify taxpayer identification information from bidders and contractors engaging with the state. The document requires respondents to certify their correct taxpayer identification number and confirm they are not subject to backup withholding by the Internal Revenue Service. The form accommodates various entity types including individuals, sole proprietors, partnerships, corporations, limited liability companies, estates or trusts, and tax-exempt organizations. Respondents must provide their legal name or business name along with either a Social Security Number or Employer Identification Number, depending on their legal status. The form requires an authorized representative signature and date to validate the submission.
The form includes specific instructions for different business structures to ensure accurate identification data submission. Sole proprietors must list the owner's name followed by the business name with the corresponding SSN or EIN, while single-member LLCs disregarded as separate entities follow similar requirements. Corporations and partnerships must provide their entity business name and EIN, with corporations required to attach IRS acceptance letters (CP261 or CP277). Entities providing or billing for medical and/or health care services must indicate their tax classification. This form serves as a prerequisite documentation requirement for state contract opportunities and does not contain specific contract pricing, scope details, or award information.
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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 .