DUNS Number; ▇▇▇ Registration; Nature of Entity Clause Samples

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that _ is Grantee’s correct DUNS Number, that _ is Grantee’s correct UEI, if applicable, that is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and ▇▇▇ registration. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate 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 □ P = partnership Estate or Trust □ C = corporation If Grantee has not received a payment from the state of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079130928 is ▇▇▇▇▇▇▇’s correct DUNS number, that ▇▇-▇▇▇▇▇▇▇ is ▇▇▇▇▇▇▇’s correct FEIN or Social Security Number, and that Grantee has an active State registration and ▇▇▇ registration. ▇▇▇▇▇▇▇ is doing business as a (check one): Individual Pharmacy-Non Corporate 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 P = partnership Estate or Trust C = corporation If Grantee has not received a payment from the state of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that is ▇▇▇▇▇▇▇’s correct DUNS number, that is ▇▇▇▇▇▇▇’s correct FEIN or Social Security Number, and that Grantee has an active State registration and ▇▇▇ registration (if federal funds). Grantee is doing business as a (check): 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

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that «DunsNumber» is ▇▇▇▇▇▇▇’s correct DUNS Number; «UEI» is ▇▇▇▇▇▇▇’s correct UEI, if applicable; Grantee has an active State registration and ▇▇▇ registration; and «FeinSsn» is Grantee’s correct FEIN or Social Security Number. Grantee further certifies, if applicable: (a) that Grantee is not subject to backup withholding because (i) Grantee is exempt from backup withholding, or (ii) Grantee has not been notified by the Internal Revenue Service (IRS) that Grantee is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified Grantee that Grantee is no longer subject to backup withholding; and (b) Grantee is a U.S. citizen or other U.S. person. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) Limited Liability Company (select applicable tax Medical Corporation classification) Governmental Unit P = partnership Estate or Trust C = corporation If Grantee has not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that: is ▇▇▇▇▇▇▇’s correct DUNS Number; _ is Grantee’s correct UEI, if applicable; Grantee has an active State registration and ▇▇▇ registration; and _ is ▇▇▇▇▇▇▇’s correct FEIN or Social Security Number. Grantee further certifies, if applicable: (a) that Grantee is not subject to backup withholding because (i) Grantee is exempt from backup withholding, or (ii) Grantee has not been notified by the Internal Revenue Service (IRS) that Grantee is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified Grantee that Grantee is no longer subject to backup withholding; and (b) Grantee is a U.S. citizen or other U.S. person. ▇▇▇▇▇▇▇ is doing business as a (check one): Individual Pharmacy-Non Corporate 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 □ P = partnership Estate or Trust □ C = corporation If Grantee has not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that _057428943_ is ▇▇▇▇▇▇▇’s correct DUNS Number, that is ▇▇▇▇▇▇▇’s correct UEI, if applicable, that _37-6001569_ is ▇▇▇▇▇▇▇’s correct FEIN or Social Security Number, and that Grantee has an active State registration and ▇▇▇ registration. Grantee is doing business as a (check one): Individual Pharmacy-Non Corporate 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 □ P = partnership Estate or Trust □ C = corporation

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that is Grantee’s correct DUNS number, that is Grantee’s correct FEIN or Social Security Number, and that Grantee has an active State registration and ▇▇▇ registration (if federal funds).. Grantee is doing business as a (check one): Individual Nonresident AlienPharmacy-Non Corporate 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 entityP = partnership Estate or Trust C = corporation If Grantee has Pharmacy-Non Corporate P = partnership not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 079148581 is ▇▇▇▇▇▇▇’s correct DUNS number, that ▇▇-▇▇▇▇▇▇▇ is ▇▇▇▇▇▇▇’s correct FEIN, that VX21JWKQRG41 is Grantee’s correct UEI, if applicable and that Grantee has an active State registration and ▇▇▇ registration. Grantee further certifies, if applicable: (a) that Grantee is not subject to backup withholding because (i) Grantee is exempt from backup withholding, or (ii) Grantee has not been notified by the Internal Revenue Service (IRS) that Grantee is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified Grantee that Grantee is no longer subject to backup withholding; and (b) Grantee is a U.S. citizen or other U.S. person. Grantee is doing business as a Government Unit. If Grantee has not received a payment from the State of Illinois in the last two years, Grantee must submit a W-9 tax form with this Agreement.

DUNS Number; ▇▇▇ Registration; Nature of Entity. Under penalties of perjury, Grantee certifies that 082044694 is ▇▇▇▇▇▇▇’s correct DUNS number, that “UEI” is Grantee’s correct UEI, if applicable, that ▇▇-▇▇▇▇▇▇▇ is Grantee’s correct FEIN, and that Grantee has an active State registration and ▇▇▇ registration. Grantee is doing business as a Government Unit.