TAXPAYER CERTIFICATION. 1.1. Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that _________________ is Provider’s correct ____ Federal Taxpayer Identification Number or ____ Social Security Number (check one). Provider is doing business as a (please check one): 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 State of Illinois/Department of Human Services COMMUNITY SERVICES AGREEMENT FISCAL YEAR 2014 / 5 7 13 Page 2 of 42
1.2. Estimated Amount of Agreement. The estimated amount payable by DHS to Provider under this Agreement is $______________. Provider agrees to accept DHS’ payment for services rendered as specified in the Exhibits incorporated as part of this Agreement.
TAXPAYER CERTIFICATION. A duly executed Taxpayer I.D. Certification in the form attached to this Agreement as Exhibit G.
TAXPAYER CERTIFICATION. (a) U.S. Citizens and Residents. Subscriber, if a U.S. citizen or resident, certifies under penalties of perjury, that: (i) the number shown on the applicable Informational Questionnaire accompanying this Subscription Agreement is Subscriber's correct Social Security or taxpayer identification number (or Subscriber is waiting for a number to be issued); and (ii) Subscriber is not subject to backup withholding because (x) Subscriber is exempt from backup withholding, (y) Subscriber has not been notified by the Internal Revenue Service ("IRS") that Subscriber is subject to backup withholding as a result of a failure to report all interest or dividends, or (z) the IRS has notified Subscriber that Subscriber is no longer subject to backup withholding. Subscriber agrees to strike out the language in (ii) above if Subscriber is unable to make this certification.
(b) Non-U.S.
TAXPAYER CERTIFICATION. 1.1. Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that _________________ is Provider’s correct ____ Federal Taxpayer Identification Number or ____ Social Security Number (check one). Provider is doing business as a (please check one): 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
1.2. Estimated Amount of Agreement. The estimated amount payable by DHS to Provider under this Agreement is $______________. Provider agrees to accept DHS’ payment for services rendered as specified in the Exhibits incorporated as part of this Agreement.
TAXPAYER CERTIFICATION. 1.1. Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). Provider is doing business as a (please check one): 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 State of Illinois/Department of Human Services COMMUNITY SERVICES AGREEMENT FISCAL YEAR 2014 / 5 7 13 Page 2 of 42
1.2. Estimated Amount of Agreement. The estimated amount payable by DHS to Provider under this Agreement is $ . Provider agrees to accept DHS’ payment for services rendered as specified in the Exhibits incorporated as part of this Agreement.
TAXPAYER CERTIFICATION. 1
1.1. Federal Taxpayer Identification Number; Nature of Entity 1
1.2. Estimated Amount of Agreement 2 1.3. Term 2 1.4. Certification 2 1.5. Signatures 2 2.1. Standing and Authority 3 2.2. Compliance with Internal Revenue Code 3 2.3. Compliance with Federal Funding Accountability and Transparency Act of 2006 3 2.4. DUNS Number 3 2.5. Compliance with American Recovery and Reinvestment Act (ARRA) 3 ARTICLE III DEFINITIONS 3 3.1. Definitions 3 ARTICLE IV PAYMENT 6
4.1. Availability of Appropriation 6
4.2. Illinois Grant Funds Recovery Act 6 4.3. Cash Management Improvement Act of 1990 6
TAXPAYER CERTIFICATION. (Provider MUST complete) Under penalties of perjury, the Provider certifies that is the Provider’s correct Federal Taxpayer Identification Number/Social Security Number (check one). The Provider is doing business as a (please check one). 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 The Provider also certifies that it does and will comply with all provisions of the Federal Internal Revenue Code, the Illinois Revenue Act, and all rules promulgated thereunder, including withholding provisions and timely deposits of employee taxes and unemployment insurance taxes.
TAXPAYER CERTIFICATION. 1
1.1. Federal Taxpayer Identification Number; Nature of Entity 1
1.2. Estimated Amount of Agreement 12 1.3. Term 2 1.4. Certification 2 1.5. Signatures 2 2.1. Standing and Authority 3 2.2. Compliance with Internal Revenue Code 3 2.3. Compliance with Federal Funding Accountability and Transparency Act of 2006 3 2.4. DUNS Number 3 2.5. Compliance with American Recovery and Reinvestment Act (ARRA) 3 3.1. Definitions 3
4.1. Availability of Appropriation 6
4.2. Illinois Grant Funds Recovery Act 6 4.3. Cash Management Improvement Act of 1990 6
TAXPAYER CERTIFICATION. Under penalties of perjury, the Service Provider certifies that the name (stated above), federal taxpayer identification number and legal status listed below are correct. Federal Taypayer Identification Number: Legal Status: (check one) Owner of sole proprietorship Partnership Tax-exempt hospital or extended care facility Corporation providing or billing medical and/or health care services Corporation NOT providing or billing medical and/or health care services Governmental entity Estate or legal trust Foreign corporation, partnership, estate or trust Other Reset Form Print Form IL462-2029 (R-4-09) Page 1 of 2
TAXPAYER CERTIFICATION
