TIN form blank~39.docx

This is a Taxpayer Identification Number (TIN) form issued by the State of Illinois for use in state and local contract opportunities. The form serves as a certification document where contractors and vendors must provide their correct taxpayer identification information and confirm their compliance with backup withholding requirements as established by the Internal Revenue Service. The form accommodates various entity types including individuals, sole proprietors, partnerships, corporations, limited liability companies, governmental entities, estates or trusts, and tax-exempt organizations. 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 requires selection of the appropriate legal status category and, for certain entity types such as corporations providing medical and health care services, specification of the applicable tax classification.

Completion and submission of this form is a standard requirement for all vendors and contractors seeking to engage in state and local contracting opportunities with the State of Illinois. The form must be signed by an authorized representative and includes a date field for execution. Corporations providing or billing for medical and/or health care services must attach relevant IRS acceptance letters (CP261 or CP277) to substantiate their entity status. This documentation is essential for tax compliance verification and ensures that all parties conducting business with the state have been properly identified and vetted for withholding and reporting purposes.