Common use of Contractor Certification to Covered Agency Clause in Contracts

Contractor Certification to Covered Agency. (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) For information, consult Publication 223, Question and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) Contractor's federal employer identification number (EIN) Contractor's sales tax ID number (if different from contractor's EIN) $ Contractor's telephone number ( ) Covered agency name Covered agency address Covered agency telephone number I, ________________________________ , hereby affirm, under penalty of perjury, that I am ______________________________ (name) (title) of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark an X in only one box) The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete. The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form T-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time. Sworn to this______ day of _________, 20 ____ (sign before a notary public) (title)

Contractor Certification to Covered Agency. (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) For information, consult Publication 223, Question and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) Contractor's federal employer identification number (EIN) Contractor's sales tax ID number (if different from contractor's EIN) $ Contractor's telephone number ( ) Covered agency name Covered agency address Covered agency telephone number I, ________________________________ , hereby affirm, under penalty of perjuryxxxxxxx, that I am ______________________________ (name) (title) of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark an X in only one box) The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete. The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form T-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time. Sworn to this______ this day of _________, 20 ____ (sign before a notary public) (title)

Contractor Certification to Covered Agency. (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) For information, consult Publication 223, Question and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) Contractor's federal employer identification number (EIN) Contractor's sales tax ID number (if different from contractor's EIN) $ Contractor's telephone number ( ) Covered agency name Covered agency address Covered agency telephone number I, ________________________________ , hereby affirm, under penalty of perjury, that I am ______________________________ (name) (title) of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark Xxxx an X in only one box) The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete. The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form T-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time. Sworn to this______ this day of _________, 20 ____ (sign before a notary public) (title)

Contractor Certification to Covered Agency. (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) For information, consult Publication 223, Question and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) Contractor's federal employer identification number (EIN) Contractor's sales tax ID number (if different from contractor's EIN) $ Contractor's telephone number ( ) Covered agency name Covered agency address Covered agency telephone number I, ________________________________ , hereby affirm, under penalty of perjury, that I am ______________________________ (name) (title) of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark Xxxx an X in only one box) The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete. The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form T-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time. Sworn to this______ day of _________, 20 ____ (sign before a notary public) (title)

Contractor Certification to Covered Agency. (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) For information, consult Publication 223, Question and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) $ Contractor's federal employer identification number (EIN) Contractor's sales tax ID number (if different from contractor's EIN) $ Contractor's telephone number ( ) Covered agency name Covered agency address Covered agency telephone number I, ________________________________ , hereby affirm, under penalty of perjuryxxxxxxx, that I am ______________________________ (name) (title) of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark an X in only one box) The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete. The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form T-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time. Sworn to this______ this day of _________, 20 ____ (sign before a notary public) (title) General Information Instructions Note: Form ST-220-CA must be signed by a person authorized to make the Tax Law section 5-a was amended, effective April 26, 2006. On or after that date, in all cases where a contract is subject to Tax Law section 5-a, a contractor must file (1) Form ST-220-CA, Contractor Certification to Covered Agency, with a covered agency, and (2) Form ST-220-TD with the Tax Department before a contract may take effect. The circumstances when a contract is subject to section 5-a are listed in Publication 223, Q&A 3. This publication is available on our Web site, by fax, or by mail. (See Need help? for more information on how to obtain this publication.) In addition, a contractor must file a new Form ST-220-CA with a covered agency before an existing contract with such agency may be renewed. If you have questions, please call our information center at 0 000 000-0000. certification on behalf of the contractor, and the acknowledgement on page 2 of this form must be completed before a notary public. When to complete this form As set forth in Publication 223, a contract is subject to section 5-a, and you must make the required certification(s), if:

Contractor Certification to Covered Agency. (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) For information, consult Publication 223, Question and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) Contractor's federal employer identification number (EIN) Contractor's sales tax ID number (if different from contractor's EIN) $ Contractor's telephone number ( ) Covered agency name OGS, Procurement Services Group Covered agency address Corning Tower, The Governor Xxxxxx X. Xxxxxxxxxxx Plaza, Albany, NY 12242 Covered agency telephone number (000) 000-0000 I, ________________________________ , hereby affirm, under penalty of perjury, that I am ______________________________ (nameName) (titleTitle) of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark an X in only one box) The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete. The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert Insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form T-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time. Sworn to this______ day of _________, 20 ____ (sign before a notary public) (title)