TIN form blank~57.docx
DOCX document 30 KB Posted
- Attached to
- Appliance Insp-Mnt J0140 Spfld
- Solicitation number
- 27-416CMS-BOPM4-B-53514
- Issued by
- Sangamon County, Illinois
About this file
This is a Taxpayer Identification Number (TIN) form from the State of Illinois used for contractor registration and compliance purposes. The form requires contractors to provide their correct taxpayer identification number and certify that 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, and tax-exempt organizations. Contractors must select their legal status and provide corresponding identifying information, whether a Social Security Number for individuals or an Employer Identification Number for business entities. Corporations providing medical and health care services must attach IRS acceptance letters (CP261 or CP277) with their submission.
The form requires the authorized representative's signature and date of completion. It serves as a prerequisite documentation requirement for entities bidding on or entering into contracts with the State of Illinois, ensuring proper tax identification and withholding compliance. No specific pricing terms, set-asides, contract amounts, or performance timelines are addressed within this form, as it functions solely as a tax identification and certification document rather than a substantive contract document.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Contract Appliance Insp-Mnt J0140 Spfld~2.docx | DOCX document | |
| Pre-Bid Walk Through Notice-Mandatory Appliance Maint Rerpair B-53514 J0140 Spfld.docx | DOCX document | |
| Attachment A Appliance Listing.pdf | ||
| standard-illinois-certifications-v-26-2~46.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:
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 .