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: