AFFIDAVIT of COMPLIANCE with TAX LAWS

AFFIDAVIT of COMPLIANCE with TAX LAWS

State of ______

County of ______

______(Affiant), being first duly sworn under oath and representing [insert Bidder/Proposer Name] (hereafter ["Bidder"/ "Proposer”]), hereby deposes and swears or affirms under penalty of perjury that:

1.  I am an employee of [Bidder/Proposer], I have knowledge of the [Invitation to Bid/Request for Proposals] referenced herein, and I have full authority from the [Bidder/Proposer] to submit this affidavit and accept the responsibilities stated herein.

2.  I am aware that the Proposer has submitted a Proposal, dated on or about [insert date] (the ["Bid"/ “·Proposal"]), to the State of Oregon (State) in response to Request for Proposals [insert number], for [insert brief description of the goods and/or services sought in the RFP] and I am familiar with the contents of the [Invitation to Bid and Bid/Request for Proposals and Proposal].

3.  The number shown on this form is [Bidder's/Proposer's] correct taxpayer identification;

A.  Federal Tax Number:

B. Oregon Tax Number:

4.  [Bidder/Proposer]is not subject to backup withholding because (i) [Bidder/Proposer] is exempt from backup withholding, (ii) [Bidder/Proposer] has not been notified by the IRS that [Bidder/Proposer] is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified [Bidder/Proposer] that [Bidder/Proposer] is no longer subject to backup withholding;

5.  I am authorized to act on behalf of [Bidder/Proposer], and have authority and knowledge regarding [Bidder's/Proposer's] payment of taxes, and to the best of my knowledge, [Bidder/Proposer] is not in violation of any Oregon tax laws, including, without limitation, those tax laws listed in ORS 305.380(4), namely ORS Chapters 118, 314, 316, 317, 318, 320, 321 and 323 and Sections 10 to 20, Chapter 533, Oregon Laws 1981, as amended by Chapter 16, Oregon Laws 1982 (first special session); the elderly rental assistance program under ORS 310.630 to 310.706; and any local taxes administered by the Oregon Department of Revenue under ORS 305.620.

Affiant's Signature

Signed and sworn to before me on (date) by (Affiant's name).

Notary Public for the State of _

My Commission Expires:

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