Taxpayer Identification Page~9.docx
DOCX document 27 KB Posted
- Attached to
- IDOC- 7. 5oz Kelly Green Twill
- Solicitation number
- 26-426DOC-CENTR-B-51444
- Issued by
- Madison County, Illinois
About this file
This is a Taxpayer Identification Number (TIN) form issued by the State of Illinois Chief Procurement Office for General Services Contract. The form is a certification document designed to collect taxpayer identification information from bidders and contractors engaging with the state. The document requires vendors to provide either their Social Security Number (for individuals and sole proprietors) or Employer Identification Number (for business entities), along with certification that the provided number is correct and that the contractor is not subject to backup withholding by the Internal Revenue Service. The form accommodates various legal entity structures, including individuals, sole proprietors, partnerships, corporations, limited liability companies, tax-exempt organizations, and specialized entities such as pharmacies, funeral homes, and medical service providers.
Contractors must certify their U.S. person status and confirm compliance with IRS backup withholding requirements before submission. The form requires an authorized representative's signature and date. This document serves as a prerequisite compliance requirement for state contracting and is part of the standard procurement documentation package, establishing baseline verification of contractor identity and tax compliance status prior to contract award and payment processing.
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Other files
| File | Type | Posted |
|---|---|---|
| Unsigned Contract-Centralia Kelly Green Twill - B-51444 Contract ~1.docx | DOCX document | |
| Standard-terms-and-conditions~3.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 .