TIN page v.23.1~20.docx
DOCX document 30 KB Posted
- Solicitation number
- 26-557THA-PROCU-B-48766
- Issued by
- Lake County, Lee Center CDP, Illinois
About this file
This document is a Taxpayer Identification Number (TIN) form issued by the State of Illinois Chief Procurement Office for General Services. The form is designed for vendors, contractors, or service providers to provide their tax identification details when engaging in state business transactions. The form requires completion of identifying information including legal status, business name, taxpayer identification number (either Social Security Number or Employer Identification Number), and signature of an authorized representative.
The form provides detailed instructions for different entity types, including individuals, sole proprietors, single-member LLCs, corporations, and partnerships, specifying how each should complete their tax identification information. Filers must certify their taxpayer identification number's accuracy and confirm their status regarding backup withholding. The document includes multiple checkboxes for legal status classification, ranging from individual and governmental entities to various corporate and medical service provider structures, allowing precise categorization of the business or organization submitting the form.
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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 for General Services 3Taxpayer Identification Number (TIN) V.23.1
File details come from the government source that posted it. Updated .