DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that is Grantee’s correct DUNS number, that is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit □ P = partnership Estate or Trust □ C = corporation If Grantee has not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 029980307 is Grantee’s correct DUNS number, that 366006548 is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Grantee is doing business as a (check one): Individual Pharmacy - Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit P = partnership Estate or Trust C = corporation If Grantee has not received a payment from the State of Illinois in the last two years. Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that _ is Grantee’s correct DUNS Number, that _ is Grantee’s correct UEI, if applicable, that is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit □ P = partnership Estate or Trust □ C = corporation If Grantee has not received a payment from the state of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that is Grantee’s correct DUNS number, that is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration (if federal funds). Grantee is doing business as a (check): Individual Nonresident Alien Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit D = disregarded entity Estate or Trust C = corporation Pharmacy-Non Corporate P = partnership
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that «DunsNumber» is Xxxxxxx’s correct DUNS Number; «UEI» is Xxxxxxx’s correct UEI, if applicable; Grantee has an active State registration and XXX registration; and «FeinSsn» is Grantee’s correct FEIN or Social Security Number. Grantee further certifies, if applicable: (a) that Grantee is not subject to backup withholding because (i) Grantee is exempt from backup withholding, or (ii) Grantee has not been notified by the Internal Revenue Service (IRS) that Grantee is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified Grantee that Grantee is no longer subject to backup withholding; and (b) Grantee is a U.S. citizen or other U.S. person. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select applicable tax Medical Corporation classification) Governmental Unit P = partnership Estate or Trust C = corporation If Grantee has not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that: is Xxxxxxx’s correct DUNS Number; _ is Grantee’s correct UEI, if applicable; Grantee has an active State registration and XXX registration; and _ is Xxxxxxx’s correct FEIN or Social Security Number. Grantee further certifies, if applicable: (a) that Grantee is not subject to backup withholding because (i) Grantee is exempt from backup withholding, or (ii) Grantee has not been notified by the Internal Revenue Service (IRS) that Grantee is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified Grantee that Grantee is no longer subject to backup withholding; and (b) Grantee is a U.S. citizen or other U.S. person. Xxxxxxx is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit P = partnership Estate or Trust C = corporation If Grantee has not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that is Xxxxxxx’s correct DUNS Number, that is Xxxxxxx’s correct UEI, if applicable, that is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Xxxxxxx is doing business as a (check one): ☐Individual ☐Pharmacy-Non Corporate ☐Sole Proprietorship ☐Pharmacy/Funeral Home/Cemetery Corp. ☐Partnership ☐Tax Exempt ☐Corporation (includes Not For Profit) ☐Limited Liability Company (select ☐Medical Corporation applicable tax classification) ☐Governmental Unit ☐P = partnership ☐Estate or Trust ☐C = corporation If Grantee has not received a payment from the state of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 135836026 is Grantee’s correct DUNS Number, that XXX _ is Grantee’s correct UEI, if applicable, that 36-6006551_ is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit □ P = partnership Estate or Trust □ C = corporation
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 945811698 is Grantee’s correct DUNS Number, that 366006036 is Grantee’s correct UEI, if applicable, that 366006036 is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit □ P = partnership Estate or Trust □ C = corporation If Grantee has not received a payment from the state of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079148581 is Xxxxxxx’s correct DUNS number, that 00-0000000 is Xxxxxxx’s correct FEIN, that VX21JWKQRG41 is Grantee’s correct UEI, if applicable and that Grantee has an active State registration and XXX registration. Grantee further certifies, if applicable: (a) that Grantee is not subject to backup withholding because
