TIN Page~3.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY26 BAS System Preventative Maintenance
- Solicitation number
- 26-497DVA-MANTE-B-47264
- Issued by
- Kane County, Illinois
About this file
This document is a Taxpayer Identification Number (TIN) form issued by the State of Illinois Chief Procurement Office for General Services, specifically the IPG Active Registered Vendor Disclosure form (V.23.1). The form is designed for vendors to provide their taxpayer identification information and certify their status for potential state contracting opportunities. It requires vendors to enter their legal name, business name, and either a Social Security Number (SSN) or Employer Identification Number (EIN), along with selecting their legal business status from a comprehensive list of entity types.
The form includes critical certification statements regarding taxpayer identification, backup withholding status, and U.S. person classification. Vendors must provide specific details based on their business structure, such as individual owners for sole proprietorships or single-member LLCs, or full business entity information for corporations and partnerships. The document also requires the signature of an authorized representative to validate the provided information, indicating the vendor's intent to be registered and compliant with state procurement requirements.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| IVHM BAS System RFQ~3.docx | DOCX document | |
| BB.Standard Terms and Conditions v.23_98~39.pdf | ||
| IVHM BAS System Appendix A~3.docx | DOCX document | |
| standard-illinois-certifications-v.23.1~16.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 .