myBenefits/myWorkspace Systems Integrator RFP
Prepared By: Office of Temporary and Disability Assistance
Division of Operations and Program Support
Bureau of Information Technology
myBenefits/myWorkspace Systems Integrator RFP Appendix B.2.1
ST-220-CA Contractor Certification to Covered Agency
(Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006) (6/06) ; ;For information, consult Publication 223, Questions and Answers Concerning Tax Law Section 5-a (see Need Help? on back). Contractor name For covered agency use only Contract number or description Contractor’s principal place of business City State ZIP code Contractor’s mailing address (if different than above) Estimated contract value over the full term of contract (but not including renewals) 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 name Covered agency address Covered agency telephone number I, , hereby affirm, under penalty of perjury, that I am (name) (title)
of the above-named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that: (Mark an X in only one box)
;;The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of
contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete.
;;The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description)
and, to the best of the contractor’s knowledge, the information provided on that previously filed Form ST-220-TD, is correct and complete as
of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time.
Sworn to this day of , 20
(sign before a notary public) (title)
Instructions Note: Form ST-220-CA must be signed by a person authorized to make General information the certification on behalf of the contractor, and the acknowledgement Tax Law section 5-a was amended, effective April 26, 2006. On or on page 2 of this form must be completed before a notary public. after that date, in all cases where a contract is subject to Tax Law section 5-a, a contractor must file (1) Form ST-220-CA, Contractor When to complete this form Certification to Covered Agency, with a covered agency, and As set forth in Publication 223, a contract is subject to section 5-a, and (2) Form ST-220-TD with the Tax Department before a contract may you must make the required certification(s), if: take effect. The circumstances when a contract is subject to section i. The procuring entity is a covered agency within the meaning of the 5-a are listed in Publication 223, Q&A 3. This publication is available
statute (see Publication 223, Q&A 5); on our Web site, by fax, or by mail. (See Need help? for more information on how to obtain this publication.) In addition, a ii. The contractor is a contractor within the meaning of the statute (see contractor must file a new Form ST-220-CA with a covered agency Publication 223, Q&A 6); and before an existing contract with such agency may be renewed. iii. The contract is a contract within the meaning of the statute. This is If you have questions, please call our information center at the case when it (a) has a value in excess of $100,000 and (b) is a 1 800 698-2931. contract for commodities or services, as such terms are defined for purposes of the statute (see Publication 223, Q&A 8 and 9). Furthermore, the procuring entity must have begun the solicitation to purchase on or after January 1, 2005, and the resulting contract must have been awarded, amended, extended, renewed, or assigned on or after April 26, 2006 (the effective date of the section 5-a amendments).
Page 2 of 2 ST-220-CA (6/06)
Individual, Corporation, Partnership, or LLC Acknowledgment STATE OF }
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
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
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.
;;(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.
;;(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.
Internet access: www.nystax.gov (for information, forms, and publications) Privacy notification ;The Commissioner of Taxation and Finance may collect and maintain personal Fax-on-demand forms: 1 800 748-3676 ;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 Telephone assistance is available from that Law; and may require disclosure of social security numbers pursuant to ;8:00 A.M. to 5:00 P.M. (eastern time), 42 USC 405(c)(2)(C)(i). ;Monday through Friday. 1 800 698-2931 This information will be used to determine and administer tax liabilities and, when ;To order forms and publications: 1 800 462-8100 authorized by law, for certain tax offset and exchange of tax information programs as well as for any other lawful purpose. From areas outside the U.S. and outside Canada: (518) 485-6800 Information concerning quarterly wages paid to employees is provided to certain state Hearing and speech impaired (telecommunications agencies for purposes of fraud prevention, support enforcement, evaluation of the device for the deaf (TDD) callers only): 1 800 634-2110 effectiveness of certain employment and training programs and other purposes authorized by law. Persons with disabilities: In compliance with the Failure to provide the required information may subject you to civil or criminal penalties, or Americans with Disabilities Act, we will ensure that our lobbies, both, under the Tax Law. offices, meeting rooms, and other facilities are accessible to ;persons with disabilities. If you have questions about special This information is maintained by the Director of Records Management and Data ;Entry, NYS Tax Department, W A Harriman Campus, Albany NY 12227; telephone accommodations for persons with disabilities, please call 1 800 972-1233. 1 800 225-5829. From areas outside the United States and outside Canada, call (518) 485-6800.