TIN form blank~39.docx
DOCX document 29 KB Posted
- Attached to
- RR-25-6002 Systemwide, Pavement Repairs
- Solicitation number
- 26-557THA-ENGCO-B-51024
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) form blank issued by the State of Illinois for use in conjunction with the RR-25-6002 Systemwide, Pavement Repairs contract opportunity. The form is a standard certification document required from prospective bidders and contractors to verify their correct taxpayer identification information and confirm they are not subject to backup withholding by the Internal Revenue Service. The form accommodates various business entity types, including individuals, sole proprietors, partnerships, corporations, limited liability companies, and tax-exempt organizations, with specific instructions for how each entity type should complete the name and identification number fields.
The form requires bidders to provide their legal business name, taxpayer identification number (either a Social Security Number or Employer Identification Number), and legal status classification. Completion of this form is mandatory for submission in response to the State of Illinois solicitation, as electronic submissions are required per CPO Notice 2023.12, with paper responses explicitly not accepted. An authorized representative must sign and date the form to certify the accuracy of the taxpayer identification information provided.
View the file
Other files
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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:
Business Name:
Taxpayer Identification Number:
Social Security Number:
or Employer Identification Number:
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) | ||||
| |X| 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 .