TIN Page~16.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY 27 Dietitian Services
- Solicitation number
- 27-497DVA-MANTE-B-54205
- Issued by
- Illinois
About this file
This is a Taxpayer Identification Number (TIN) disclosure form from the State of Illinois Chief Procurement Office for General Services, used for vendor registration and compliance with federal backup withholding requirements. The form requires vendors to provide their correct taxpayer identification information, certify their withholding status, and confirm their U.S. person status. Vendors must submit their legal name, business name if applicable, and either their Social Security Number or Employer Identification Number depending on their business structure, which includes options for individuals, sole proprietors, partnerships, corporations, limited liability companies, and other entity types. The form requires signature and date confirmation from an authorized representative.
The form serves as a prerequisite for the IVHM FY 27 Dietitian Services contract opportunity with the State of Illinois. This contract requires provision of dietitian services for facility operations with an execution date through June 30, 2027, with no subcontracting permitted. All questions regarding this opportunity must be submitted to travis.kutemeier@illinois.gov by September 28, 2026. Vendors responding to this opportunity must complete and submit the TIN disclosure form as part of their registration with the State of Illinois Chief Procurement Office.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| IVHM Dietitian Bidding Documents FINAL~3.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .