New	York	State	Department	of	Taxation	and	Finance
	
Contractor	Certification	to	Covered	Agency
	
(Pursuant	to	Section	5-a	of	the	Tax	Law,	as	amended,	effective	April	26,	2006)
ST-220-CA
(6/06)
	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	name
	Covered	agency	address
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)
G	 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.	
G	 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)
For covered agency use only
Contract number or description
Estimated contract value over
the full term of contract (but not
including renewals)
$
Covered agency telephone number
For	information,	consult	Publication	223,	Questions and Answers Concerning Tax Law Section 5-a	(see	Need Help? on back).
Instructions
General	information
Tax	Law	section	5-a	was	amended,	effective	April	26,	2006.	On	or	
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
Certification to Covered Agenc