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