TAX CERTIFICATION AFFIDAVIT FOR CONTRACTS ______________________ ______________________ _____________________ Individual Social Security Number State Identification Number Federal Identification Number Company: _______________________________________________________________________________ _____________ P.O. Box (if any): ____________________________ Street Address Only: ______________________________________________ City/State/Zip Code: _____________________________________________________________________________________________ Telephone Number: ___________________________________ Fax Number: __________________________________ List address(es) of all other property owned by company in Springfield: __________________________________________________________ Please Identify if the bidder/proposer is a: Corporation _________ Individual _________ Name of Individual: _________________________________________________________ Partnership _________ Names of all Partners: _______________________________________________________ Limited Liability Company _________ Names of all Managers: ______________________________________________________ Limited Liability Partnership _________ Names of Partners: _________________________________________________________ Limited Partnership _________ Names of all General Partners: ________________________________________________ You must complete the following certifications and have the signature(s) notarized on the lines below. Any certification that does not apply to you, write N/A in the blanks provided. FEDERAL TAX CERTIFICATION I, ________________________ certify under the pains and penalties of perjury that _________________, to my best knowledge and (authorized agent) (Bidder/Proposer) belief, has/have complied with all United States Federal taxes required by law. ______________________________ ________________________________ Date: ______________________ Bidder/Proposer Authorized Person’s Signature CITY OF SPRINGFIELD TAX CERTIFICATION I, ________________________ certify under the pains and penalties of perjury that _________________, to my best knowledge and (authorized agent) (Bidder/Proposer) belief, has/have complied with all City of Springfield taxes required by law(has/have entered into a Payment Agreement with the City). ______________________________ ________________________________ Date: ______________________ Bidder/Proposer Authorized Person’s Signature COMMONWEALTH OF MASSACHUSETTS TAX CERTIFICATION Pursuant to M.G.L. c. 62C '49A, I, ________________________ certify under the pains and penalties of perjury that _________________, (authorized agent) (Bidder/Proposer) to my best knowledge and belief, has/have filed all state tax returns and has/have complied with all state taxes required by law. ______________________________ ________________________________ Date: ______________________ Bidder/Proposer Authorized Person’s Signature
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