TIN Page~3.pdf
PDF 494 KB Posted
- Solicitation number
- 27-497DVA-MANTE-B-51576
- 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, required for vendor registration and compliance with backup withholding requirements. The form is associated with the IVHM FY 27 Building Automation System Maintenance contract opportunity, which involves providing labor and materials for the maintenance of a facility's building automation system for the contract period of July 1, 2026 through June 30, 2027. All questions regarding this opportunity must be submitted to travis.kutemeier@illinois.gov by April 20, 2026.
The TIN disclosure form requires vendors to certify their correct taxpayer identification number and confirm their exemption from IRS backup withholding. Vendors must complete the form by providing their name, business name, and either a Social Security Number or Employer Identification Number, and must indicate their legal status by selecting from categories including individual, sole proprietor, partnership, corporation, limited liability company, or other entity types such as governmental, estate or trust, legal services corporation, or tax-exempt organizations. An authorized representative must sign and date the completed form.
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Other files
| File | Type | Posted |
|---|---|---|
| IVHM BAS System Bidding Documentation.docx | DOCX document | |
| standard-terms-and-conditions2~19.pdf | ||
| standard-illinois-certifications-v.23.1~30.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 .