DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079130928 is Xxxxxxx’s correct DUNS number, that 00-0000000 is Xxxxxxx’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.
Appears in 1 contract
Samples: Grant Agreement
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079130928 029980307 is XxxxxxxGrantee’s correct DUNS number, that 00-0000000 366006548 is XxxxxxxGrantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Xxxxxxx Grantee is doing business as a (check one): Individual Pharmacy-Pharmacy - Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not for 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 State of Illinois in the last two years, . Grantee must submit a W-9 tax form with this Agreement.
Appears in 1 contract
Samples: Grant Agreement
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079130928 _057428943 is XxxxxxxGrantee’s correct DUNS number, that 00_37-0000000 6001569 is XxxxxxxGrantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Xxxxxxx 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 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 State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.
Appears in 1 contract
Samples: Inter Governmental Agreement
DUNS Number; XXX Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079130928 135836026 is XxxxxxxGrantee’s correct DUNS number, that 00-0000000 366006551 is XxxxxxxGrantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and XXX registration. Xxxxxxx 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 For Profit) Limited Liability Company (select applicable tax Medical Corporation applicable tax classification) X 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.
Appears in 1 contract
Samples: Inter Governmental Agreement