TIN Page~2.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY 26 Dietitian Services
- Solicitation number
- 26-497DVA-MANTE-B-47053
- Issued by
- Kankakee County, Illinois
About this file
The document is a State of Illinois Taxpayer Identification Number form from the State of Illinois Chief Procurement Office for General Services, specifically an IPG Active Registered Vendor Disclosure form (V.23.1). The form is designed for vendors to provide their taxpayer identification information and certify their tax status for participation in state procurement processes.
The form requires vendors to provide comprehensive identification details, including name, business name, and taxpayer identification number (either Social Security Number or Employer Identification Number). Vendors must select their legal status from multiple categories such as individual, sole proprietor, partnership, corporation, or limited liability company. The form includes certification statements regarding taxpayer identification, backup withholding status, and U.S. person classification. Vendors must also sign and date the document to validate their disclosure and compliance with state procurement requirements.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| standard-illinois-certifications-v.23.1~17.docx | DOCX document | |
| BB.Standard Terms and Conditions v.23_98~38.pdf | ||
| IVHM FY 26 Dietitian Services RFQ~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 .