Fillable Form St-220-Ca - Contractor Certification To Covered Agency (Page 2 of 2) in pdf

Page 2 of 2 ST-220-CA (12/11)

Individual, Corporation, Partnership, or LLC Acknowledgment

STATE OF

}

SS.:

COUNTY OF

}

On the

day of

in the year 20

, before me personally appeared

known to me to be the person who executed the foregoing instrument, who, being duly sworn by me did depose and say that

he resides at

Town of

County of

State of

; and further that:

[Mark an X in the appropriate box and complete the accompanying statement.]

(If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.

(If a corporation): _he is the

, the corporation described in said instrument; that, by authority of the Board

of Directors of said corporation, _he is authorized to execute the foregoing instrument on behalf of the corporation for

purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on

behalf of said corporation as the act and deed of said corporation.

(If a partnership): _he is a

, the partnership described in said instrument; that, by the terms of said

partnership, _he is authorized to execute the foregoing instrument on behalf of the partnership for purposes set forth

therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on behalf of said

partnership as the act and deed of said partnership.

(If a limited liability company): _he is a duly authorized member of

LLC, the limited liability company described in said instrument; that _he is authorized to execute the foregoing instrument

on behalf of the limited liability company for purposes set forth therein; and that, pursuant to that authority, _he executed

the foregoing instrument in the name of and on behalf of said limited liability company as the act and deed of said limited

liability company.

Notary Public

Registration No.

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personal information pursuant to the New York State Tax Law, including but

not limited to, sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096,

1142, and 1415 of that Law; and may require disclosure of social security

Telephone assistance

numbers pursuant to 42 USC 405(c)(2)(C)(i).

This information will be used to determine and administer tax liabilities

Sales Tax Information Center:

(518) 485-2889

and, when authorized by law, for certain tax offset and exchange of tax

information programs as well as for any other lawful purpose.

To order forms and publications:

(518) 457-5431

Information concerning quarterly wages paid to employees is provided

Text Telephone (TTY) Hotline (for persons with

to certain state agencies for purposes of fraud prevention, support

hearing and speech disabilities using a TTY):

(518) 485-5082

enforcement, evaluation of the effectiveness of certain employment and

training programs and other purposes authorized by law.

Persons with disabilities: In compliance with the

Americans with Disabilities Act, we will ensure that our

Failure to provide the required information may subject you to civil or

lobbies, offices, meeting rooms, and other facilities are

criminal penalties, or both, under the Tax Law.

accessible to persons with disabilities. If you have questions

This information is maintained by the Manager of Document Management,

about special accommodations for persons with disabilities, call the

NYS Tax Department, W A Harriman Campus, Albany NY 12227; telephone

information center.

(518) 457-5181.

Form St-220-Ca - Contractor Certification To Covered Agency Page 2

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