TIN page BLANK .docx
DOCX document 41 KB Posted
- Attached to
- 3rd Ventilator Maintenance EMERGENCY NOTICE
- Solicitation number
- 26-482DPH-PREPD-B-50055
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) form issued by the State of Illinois Chief Procurement Office under the General Services division. The form is a blank template designed for bidders and vendors responding to state contract opportunities, including the referenced 3rd Ventilator Maintenance emergency notice. The form certifies the bidder's correct taxpayer identification number and confirms the bidder is not subject to backup withholding by the Internal Revenue Service. Bidders must complete the form by entering their legal name, business name, and either their Social Security Number or Employer Identification Number, depending on their business structure. The form requires bidders to indicate their legal status, selecting from options including individual, sole proprietor, partnership, corporation, limited liability company, governmental entity, or tax-exempt organization, with specific instructions provided for different entity types such as single-member LLCs, medical and health care providers, and pharmacy operations.
The form serves as a required submission document for state procurement processes and does not independently establish pricing terms, set-asides, funding amounts, or contract conditions. Instead, it functions as a compliance and identification document that vendors must complete and submit alongside their bids. Completion of this form is mandatory for all bidders participating in Illinois state and local contract opportunities and must be accompanied by appropriate supporting documentation, such as IRS acceptance letters for corporations applying for state contracts.
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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: Click here to enter a date.
State of Illinois Chief Procurement Office General Services 9 Taxpayer Identification Number V.23.2
File details come from the government source that posted it. Updated .