TIN Page~10.pdf
PDF 494 KB Posted
- Attached to
- IVHM Fy 25/26 Cable Television SP- Sole Source
- Solicitation number
- 26-497DVA-MANTE-B-47072
- Issued by
- Illinois
About this file
This document is a State of Illinois Taxpayer Identification Number form from the State of Illinois Chief Procurement Office for General Services, specifically the IPG Active Registered Vendor Disclosure (V.23.1). The form is designed for vendors to provide their taxpayer identification information and certify their status for participation in state procurement processes. It requires vendors to indicate their legal status (such as individual, sole proprietor, partnership, corporation, etc.) and provide their corresponding taxpayer identification number (Social Security Number or Employer Identification Number).
The form includes detailed instructions for different types of business entities on how to complete the document, including specific guidance for individuals, sole proprietors, single-member LLCs, corporations, and other entity types. Vendors must certify that their taxpayer identification number is correct, they are not subject to backup withholding, and they are a U.S. person. The document provides checkboxes for various legal statuses and tax classifications, allowing vendors to precisely define their business structure for the state procurement system.
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Other files
| File | Type | Posted |
|---|---|---|
| BB.Standard Terms and Conditions v.23_98~21.pdf | ||
| standard-illinois-certifications-v.23.1~24.docx | DOCX document |
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Text version
STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
State of Illinois Chief Procurement Office for General Services 4 IPG Active Registered Vendor Disclosure V.23.1
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)
Corporation NOT providing or billing C = corporation medical and/or health care services P = partnership
Signature of Authorized
Representative: Date:
File details come from the government source that posted it. Updated .