TIN Page~3.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY26 BAS System Preventative Maintenance
- Solicitation number
- 26-497DVA-MANTE-B-47775
- Issued by
- Illinois
About this file
The document is a State of Illinois Taxpayer Identification Number form issued by the State of Illinois Chief Procurement Office for General Services, specifically the IPG Active Registered Vendor Disclosure (Version 23.1). This standard tax documentation form is designed for vendors to provide essential tax and business identification information when registering to do business with the state government.
The form requires vendors to certify their taxpayer identification number, backup withholding status, and U.S. person/residency status. It includes multiple sections for different types of business entities (individuals, sole proprietors, single-member LLCs, corporations, partnerships) to enter their specific identifying information. The form provides checkboxes for various legal statuses and tax classifications, allowing vendors to accurately represent their business structure. A signature line is provided for an authorized representative to complete and date the form, indicating their agreement with the certification statements.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| standard-illinois-certifications-v.23.1~16.docx | DOCX document | |
| IVHM BAS System Appendix A~3.docx | DOCX document | |
| IVHM BAS System RFQ~4.docx | DOCX document | |
| BB.Standard Terms and Conditions v.23_98~39.pdf |
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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 .