Department of Taxation and Finance
                                          Contractor Certification                                                                 ST-220-TD
                                                                                                                                                   (4/15)
                                          (Pursuant to Tax Law Section 5-a, as amended, 
                                          effective April 26, 2006)
For information, consult Publication 223, Questions and Answers Concerning Tax Law Section 5-a (see Need help? below). 
 Contractor name

 Contractor’s principal place of business                  City                                 State                              ZIP code

 Contractor’s mailing address (if different than above)    City                                 State                              ZIP code 

 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 or state agency                            Contract number or description                                        Covered agency telephone number
                                                                                                                                 ( )
 Covered agency address                                    City                                 State                              ZIP code  

 Is the estimated contract value over the full term of the contract (but not including renewals) more than $100,000?
 Yes            No              Unknown at this time

General information                                                         Privacy notification
Tax Law section 5-a, as amended, effective April 26,                        New York State Law requires all government agencies that 
2006, requires certain contractors awarded certain state                    maintain a system of records to provide notification of the 
contracts valued at more than $100,000 to certify to the Tax                legal authority for any request, the principal purpose(s) for 
Department that they are registered to collect New York                     which the information is to be collected, and where it will 
State and local sales and compensating use taxes, if they                   be maintained. To view this information, visit our Web site, 
made sales delivered by any means to locations within                       or, if you do not have Internet access, call and request 
New York State of tangible personal property or taxable                     Publication 54, Privacy Notification. See Need help? for the 
services having a cumulative value in excess of $300,000,                   Web address and telephone number.
measured over a specified period. In addition, contractors 
                                                                             
must certify to the Tax Department that each affiliate and                  Need help?
subcontractor exceeding such sales threshold during a 
specified period is registered to collect New York State                                  Visit our Web site at www.tax.ny.gov
and local sales and compensating use taxes. Contractors                                   •  get information and manage your taxes online
must also file Form ST-220-CA, Contractor Certification to 
                                                                                          •  check for new online services and features
Covered Agency, certifying to the procuring state entity that 
they filed Form ST-220-TD with the Tax Department and that                   Telephone assistance
the information contained on Form ST-220-TD is correct and 
complete as of the date they file Form ST-220-CA.                           Sales Tax Information Center:                                   (518) 485-2889
All sections must be completed including all fields on the top              To order forms and publications:                                (518) 457-5431
of this page, all sections on page 2, Schedule A on page 3, if              Text Telephone (TTY) Hotline (for persons with 
applicable, and Individual, Corporation, Partnership, or LLC                  hearing and speech disabilities using a TTY):  (518) 485-5082
Acknowledgement on page 4. If you do not complete these                      Persons with disabilities: In compliance with the 
areas, the form will be returned to you for completion.                                   Americans with Disabilities Act, we will ensure that our 
                                                                                          lobbies, offices, meeting rooms, and other facilities are
For more detailed information regarding this form and                       accessible to persons with disabilities. If you have questions 
Tax Law section 5-a, see Publication 223, Questions and                     about special accommodations for persons with disabilities, call the 
Answers Concerning Tax Law Section 5-a, (as amended,                        information center.
effective April 26, 2006). See Need help? for more 
information on how to obtain this publication.
Note: Form ST-220-TD must be signed by a person 
authorized to make the certification on behalf of the 
contractor, and the acknowledgement on page 4 of this form 
must be completed before a notary public.
Mail completed form to:
                              NYS TAX DEPARTMENT
                              DATA ENTRY SECTION
                              W A HARRIMAN CAMPUS
                              ALBANY NY 12227-0826

Page 2 of 4 ST-220-TD (4/15)

I,                                             , hereby affirm, under penalty of perjury, that I am
                 (name)                                                                                   (title)
of the above-named contractor, and that I am authorized to make this certification on behalf of such contractor.

Complete Sections 1, 2, and 3 below. Make only one entry in each section.

Section 1 – Contractor registration status

G  The contractor has made sales delivered by any means to locations within New York State of tangible personal property or taxable 
   services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax 
   quarter in which this certification is made. The contractor is registered to collect New York State and local sales and compensating use 
   taxes with the Commissioner of Taxation and Finance pursuant to Tax Law sections 1134 and 1253, and is listed on Schedule A of this 
   certification.

G  The contractor has not made sales delivered by any means to locations within New York State of tangible personal property or taxable 
   services having a cumulative value in excess of $300,000 during the four sales tax quarters which immediately precede the sales tax 
   quarter in which this certification is made.

Section 2 – Affiliate registration status

G  The contractor does not have any affiliates.

G  To the best of the contractor’s knowledge, the contractor has one or more affiliates having made sales delivered by any means to 
   locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 
   during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made, and each affiliate 
   exceeding the $300,000 cumulative sales threshold during such quarters is registered to collect New York State and local sales and 
   compensating use taxes with the Commissioner of Taxation and Finance pursuant to Tax Law sections 1134 and 1253. The contractor 
   has listed each affiliate exceeding the $300,000 cumulative sales threshold during such quarters on Schedule A of this certification.

G  To the best of the contractor’s knowledge, the contractor has one or more affiliates, and each affiliate has not made sales delivered by 
   any means to locations within New York State of tangible personal property or taxable services having a cumulative value in excess of 
   $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.

Section 3 – Subcontractor registration status

G  The contractor does not have any subcontractors.

G  To the best of the contractor’s knowledge, the contractor has one or more subcontractors having made sales delivered by any means to 
   locations within New York State of tangible personal property or taxable services having a cumulative value in excess of $300,000 during 
   the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made, and each subcontractor 
   exceeding the $300,000 cumulative sales threshold during such quarters is registered to collect New York State and local sales and 
   compensating use taxes with the Commissioner of Taxation and Finance pursuant to Tax Law sections 1134 and 1253. The contractor 
   has listed each subcontractor exceeding the $300,000 cumulative sales threshold during such quarters on Schedule A of this certification.  

G  To the best of the contractor’s knowledge, the contractor has one or more subcontractors, and each subcontractor has not made sales 
   delivered by any means to locations within New York State of tangible personal property or taxable services having a cumulative value in 
   excess of $300,000 during the four sales tax quarters which immediately precede the sales tax quarter in which this certification is made.

Sworn to this      day of                 , 20

                 (sign before a notary public)                                                     (title)

                                                                                                                 ST-220-TD (4/15) Page 3 of 4

Schedule A – Listing of each entity (contractor, affiliate, or subcontractor) exceeding $300,000 
cumulative sales threshold
List the contractor, or affiliate, or subcontractor in Schedule A only if such entity exceeded the $300,000 cumulative sales threshold during the 
specified sales tax quarters. See directions below. For more information, see Publication 223.

A                         B                                 C                                 D                  E                   F
Relationship              Name                              Address                           Federal ID number  Sales tax ID number Registration 
to                                                                                                                                   in progress
contractor

Column A –  Enter C in column A if the contractor; A if an affiliate of the contractor; or S if a subcontractor. 
Column B –  Name - If the entity is a corporation or limited liability company, enter the exact legal name as registered with the NY Department 
             of State, if applicable. If the entity is a partnership or sole proprietor, enter the name of the partnership and each partner’s given 
             name, or the given name(s) of the owner(s), as applicable. If the entity has a different DBA (doing business as) name, enter that 
             name as well.
Column C – Address - Enter the street address of the entity’s principal place of business. Do not enter a PO box.
Column D – ID number - Enter the federal employer identification number (EIN) assigned to the entity. If the entity is an individual, enter the 
             social security number of that person.
Column E –  Sales tax ID number - Enter only if different from federal EIN in column D.
Column F –  If applicable, enter an X if the entity has submitted Form DTF-17 to the Tax Department but has not received its certificate of 
             authority as of the date of this certification.

Page 4 of 4 ST-220-TD (4/15)

                        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.