Common use of Taxpayer Certification Clause in Contracts

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

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