TIN Page~8.pdf
PDF 494 KB Posted
- Attached to
- IVHM FY 26 Air Handler Cleaning
- Solicitation number
- 26-497DVA-MANTE-B-50048
- Issued by
- Kane County, Illinois
About this file
This is a Taxpayer Identification Number (TIN) disclosure form used by the State of Illinois Chief Procurement Office for General Services for vendor registration purposes. The form requires vendors to provide their correct taxpayer identification number and certify their tax compliance status with the Internal Revenue Service. The form accommodates various business structures including individuals, sole proprietors, single-member LLCs, partnerships, corporations, estates or trusts, and other entities, each with specific naming and identification number requirements based on their legal classification.
The form serves as a compliance document to verify that vendors are not subject to backup withholding and are U.S. persons or U.S. resident aliens. Vendors must provide their legal business name, the appropriate tax identification number (either Social Security Number for individuals or Employer Identification Number for entities), indicate their legal status through checkbox selection, and include relevant tax classifications for specialized entities such as those providing medical and health care services or operating as pharmacies, funeral homes, or cemeteries. An authorized representative must sign the form with the date of execution to complete the vendor disclosure and registration process with the State of Illinois.
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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 .