TIN Page~16.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY 27 Dietitian Services
- Solicitation number
- 27-497DVA-MANTE-B-51604
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) certification form from the State of Illinois Chief Procurement Office for General Services, related to the IVHM FY 27 Dietitian Services contract opportunity. The form is used to verify vendor eligibility and taxpayer identification for state procurement registration purposes. Vendors responding to the dietitian services contract, which runs from August 1, 2026 through June 30, 2027, must complete and submit this certification form as part of their registration with the state. The contract opportunity specifies that all questions regarding the services must be directed to travis.kutemeier@illinois.gov, with a deadline of July 13, 2026. The contract explicitly prohibits subcontracting, requiring the vendor to provide all dietitian services directly at the specified facility.
The TIN form requires vendors to declare their correct taxpayer identification number and confirm they are not subject to backup withholding by the Internal Revenue Service. Vendors must indicate their legal status—whether they are individuals, sole proprietors, partnerships, corporations, limited liability companies, or other eligible entities—and provide corresponding identification documentation. For corporations, vendors must attach IRS acceptance letters (CP261 or CP277). The form serves as a critical compliance document for vendor registration with the State of Illinois and must be completed and signed by an authorized representative before the vendor can proceed with contract consideration.
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Other files
| File | Type | Posted |
|---|---|---|
| IVHM Dietitian Bidding Documents FINAL.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 .