Form ST-220-TD:5/07: Contractor Certification: ST220TD

ST-220-TD
New York State Department of Taxation and Finance
(Pursuant to Section 5-a of the Tax Law, as amended,
effective April 26, 2006)
Contractor Certification
(5/07)
For information, consult Publication 223, Questions and Answers Concerning Tax Law Section 5-a (see Need help? below).
Contractor name
Contractor’s principal place of business
City
State
ZIP code
Contractor’s mailing address (if different than above)
Contractor’s federal employer identification number (EIN) Contractor’s sales tax ID number (if different from contractor’s EIN) Contractor’s telephone number
(
)
Covered agency or state agency
Contract number or description
Estimated contract value over
the full term of contract
(but not including renewals) $
Covered agency address
Covered agency telephone number
General information
Privacy notification
Section 5-a of the Tax Law, as amended, effective April 26,
2006, requires certain contractors awarded certain state
contracts valued at more than $100,000 to certify to the
Tax Department that they are registered to collect New York
State and local sales and compensating use taxes, if they
made sales delivered by any means to locations within New
York State of tangible personal property or taxable services
having a cumulative value in excess of $300,000, measured
over a specified period. In addition, contractors must certify
to the Tax Department that each affiliate and subcontractor
exceeding such sales threshold during a specified period
is registered to collect New York State and local sales
and compensating use taxes. Contractors must also file a
Form ST-220-CA, certifying to the procuring state entity that
they filed Form ST-220-TD with the Tax Department and that
the information contained on Form ST-220-TD is correct and
complete as of the date they file Form ST-220-CA.
The Commissioner of Taxation and Finance may collect
and maintain 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
numbers pursuant to 42 USC 405(c)(2)(C)(i).
All sections must be completed including all fields on the top
of this page, all sections on page 2, Schedule A on page 3, if
applicable, and Individual, Corporation, Partnership, or LLC
Acknowledgement on page 4. If you do not complete these
areas, the form will be returned to you for completion.
This information will be used to determine and administer tax
liabilities and, when authorized by law, for certain tax offset
and exchange of tax information programs as well as for any
other lawful purpose.
Information concerning quarterly wages paid to employees
is provided to certain state agencies for purposes of
fraud prevention, support enforcement, evaluation of the
effectiveness of certain employment and training programs
and other purposes authorized by law.
Failure to provide the required information may subject you
to civil or criminal penalties, or both, under the Tax Law.
This information is maintained by the Director of Records
Management and Data Entry, NYS Tax Department,
W A Harriman Campus, Albany NY 12227.
For more detailed information regarding this form and
section 5-a of the Tax Law, see Publication 223, Questions
and Answers Concerning Tax Law Section 5-a, (as amended,
effective April 26, 2006), available at www.nystax.gov.
Information is also available by calling the Tax Department’s
Contractor Information Center at 1 800 698-2931.
Internet access: www.nystax.gov
(for information, forms, and publications)
Note: Form ST-220-TD must be signed by a person
authorized to make the certification on behalf of the
contractor, and the acknowledgement on page 4 of this form
must be completed before a notary public.
Telephone assistance is available from 8:00 A.M. to 5:00 P.M.
(eastern time), Monday through Friday.
To order forms and publications:
1 800 462-8100
Sales Tax Information Center:
1 800 698-2909
From areas outside the U.S. and outside Canada:
(518) 485-6800
Mail completed form to:
NYS TAX DEPARTMENT
DATA ENTRY SECTION
W A HARRIMAN CAMPUS
ALBANY NY 12227
Need help?
Fax-on-demand forms: Hearing and speech impaired (telecommunications
device for the deaf (TDD) callers only):
1 800 748-3676
1 800 634-2110
Persons with disabilities: In compliance with the Americans with Disabilities Act, we will ensure that our lobbies, offices, meeting rooms, and other facilities are accessible to
persons with disabilities. If you have questions about special
accommodations for persons with disabilities, please call 1 800 972-1233.
Page of 4 ST-220-TD (5/07)
I,
, hereby affirm, under penalty of perjury, that I am
(name)
(title)
of the above‑named contractor, and that I am authorized to make this certification on behalf of such contractor.
Complete Sections 1, 2, and 3 below. Make only one entry in each section.
Section 1 — Contractor registration status
G
The contractor has made sales delivered by any means to locations within New York State of tangible personal property or taxable
services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax
quarter in which this certification is made. The contractor is registered to collect New York State and local sales and compensating use
taxes with the Commissioner of Taxation and Finance pursuant to sections 1134 and 1253 of the Tax Law, and is listed on Schedule A of
this certification.
G
The contractor has not made sales delivered by any means to locations within New York State of tangible personal property or taxable
services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax
quarter in which this certification is made.
Section 2 — Affiliate registration status
G
The contractor does not have any affiliates.
G
To the best of the contractor’s knowledge, the contractor has one or more affiliates having made sales delivered by any means to
locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000
during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made, and each affiliate
exceeding the $300,000 cumulative sales threshold during such quarters is registered to collect New York State and local sales and
compensating use taxes with the Commissioner of Taxation and Finance pursuant to sections 1134 and 1253 of the Tax Law. The
contractor has listed each affiliate exceeding the $300,000 cumulative sales threshold during such quarters on Schedule A of this
certification.
G
To the best of the contractor’s knowledge, the contractor has one or more affiliates, and each affiliate has not made sales delivered by
any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of
$300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.
Section 3 — Subcontractor registration status
G
The contractor does not have any subcontractors.
G
To the best of the contractor’s knowledge, the contractor has one or more subcontractors having made sales delivered by any means to
locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during
the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made, and each subcontractor
exceeding the $300,000 cumulative sales threshold during such quarters is registered to collect New York State and local sales and
compensating use taxes with the Commissioner of Taxation and Finance pursuant to sections 1134 and 1253 of the Tax Law. The
contractor has listed each subcontractor exceeding the $300,000 cumulative sales threshold during such quarters on Schedule A of this
certification.
G
To the best of the contractor’s knowledge, the contractor has one or more subcontractors, and each subcontractor has not made sales
delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in
excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.
Sworn to this
day of (sign before a notary public)
, 20
(title)
ST-220-TD (5/07) Page of 4
Schedule A — Listing of each entity (contractor, affiliate, or subcontractor) exceeding $300,000
cumulative sales threshold
List the contractor, or affiliate, or subcontractor in Schedule A only if such entity exceeded the $300,000 cumulative sales threshold during the
specified sales tax quarters. See directions below. For more information, see Publication 223.
A
Relationship to
Contractor
B
Name
C
Address
D
Federal ID Number
E
Sales Tax ID Number
F
Registration
in progress
Column A – Enter C in column A if the contractor; A if an affiliate of the contractor; or S if a subcontractor.
Column B – Name - If the entity is a corporation or limited liability company, enter the exact legal name as registered with the NY Department
of State, if applicable. If the entity is a partnership or sole proprietor, enter the name of the partnership and each partner’s given
name, or the given name(s) of the owner(s), as applicable. If the entity has a different DBA (doing business as) name, enter that
name as well.
Column C – Address - Enter the street address of the entity’s principal place of business. Do not enter a PO box.
Column D – ID number - Enter the federal employer identification number (EIN) assigned to the entity. If the entity is an individual, enter the
social security number of that person.
Column E – Sales tax ID number - Enter only if different from federal EIN in column D.
Column F – If applicable, enter an X if the entity has submitted Form DTF-17 to the Tax Department but has not received its certificate of
authority as of the date of this certification.
Page of 4 ST-220-TD (5/07)
Individual, Corporation, Partnership, or LLC Acknowledgment
STATE OF
}
:
COUNTY OF
}
On the day of
SS.:
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.]
G(If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.
G
(If a corporation): _he is the
of
, 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.
G
(If a partnership): _he is a
of
, 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.
G
(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.