New York State Department of Taxation and Finance
              Contractor Certification to Covered Agency                                                                          ST-220-CA
                                                                                                                                                    (12/11)
              (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006)
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  Xin 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)

                                                                 Instructions

General information                                                    When to complete this form
Tax Law section 5-a was amended, effective April 26, 2006. On or       As set forth in Publication 223, a contract is subject to section 5-a, and 
after that date, in all cases where a contract is subject to Tax Law   you must make the required certification(s), if:
section 5-a, a contractor must file (1) Form ST-220-CA, Contractor      i.  The procuring entity is a covered agency within the meaning of the 
Certification to Covered Agency, with a covered agency, and            statute (see Publication 223, Q&A 5);
(2) Form ST-220-TD with the Tax Department before a contract 
may take effect. The circumstances when a contract is subject to        ii.  The contractor is a contractor within the meaning of the statute (see 
section 5-a are listed in Publication 223, Q&A 3. See Need help?       Publication 223, Q&A 6); and
for more information on how to obtain this publication. In addition, a   iii.  The contract is a contract within the meaning of the statute. This is 
contractor must file a new Form ST-220-CA with a covered agency        the case when it (a) has a value in excess of $100,000 and (b) is a 
before an existing contract with such agency may be renewed.           contract for commodities or services, as such terms are defined for 
                                                                       purposes of the statute (see Publication 223, Q&A 8 and 9).
Note: Form ST-220-CA must be signed by a person authorized to make 
the certification on behalf of the contractor, and the acknowledgement Furthermore, the procuring entity must have begun the solicitation to 
on page 2 of this form must be completed before a notary public.       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 (12/11) 

                       Individual, Corporation, Partnership, or LLC Acknowledgment
STATE OF              }
                  :               SS.:
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 of                                                                                             ,
County of                                                                                           ,
State of                         ; and further that:
[Mark an Xin the appropriate box and complete the accompanying statement.]
G (If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.

G (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.

G (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.

G (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.

Notary Public

Registration No.
                                                                               
                                                                              Need help?

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