TIN Page~16.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY 27 Dietitian Services
- Solicitation number
- 27-497DVA-MANTE-B-53364
- 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 a vendor's correct taxpayer identification number and confirm the vendor's compliance with backup withholding requirements under Internal Revenue Service regulations. The form accommodates multiple entity types including individuals, sole proprietors, single-member LLCs, partnerships, corporations, tax-exempt organizations, and other business structures. Vendors are required to provide their legal entity name, business name if applicable, and either a Social Security Number or Employer Identification Number depending on their legal status. The dietitian services contract is effective upon execution through June 30, 2027, with no subcontracting permitted. All questions regarding this opportunity must be submitted to travis.kutemeier@illinois.gov by September 2, 2026.
The TIN certification form serves as a mandatory compliance document for vendor registration with the State of Illinois and is required for all vendors seeking to contract with the state. Vendors must certify under penalty of perjury that the information provided is accurate and that they are not subject to IRS backup withholding, or alternatively, that they have received notification from the IRS that backup withholding no longer applies. The form requires signature from an authorized representative and includes specific instructions for different entity classifications to ensure proper identification and tax reporting. This certification is a prerequisite step in the vendor registration process before a vendor can be considered for state and local contract opportunities.
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Other files
| File | Type | Posted |
|---|---|---|
| IVHM Dietitian Bidding Documents FINAL~2.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 .