Specifications

Page 13 of 14
Page 2 of 2 ST-220-CA (6/06)
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 X in the appropriate box and complete the accompanying statement.]
(If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.
(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.
(If a partnership): _he is
the 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.
(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.
Privacy notification
The Commissioner of Taxation and Finance may collect and maintain personal
information pursuant to the New York State Tax Law, including but not limited to,
sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that
Law; and may require disclosure of social security numbers pursuant to 42 USC
405(c)(2)(C)(i).
This information will be used to determine and administer tax liabilities and, when
authorized by law, for certain tax offset and exchange of tax information programs as
well as for any other lawful purpose.
Information concerning quarterly wages paid to employees is provided to certain state
agencies for purposes of fraud prevention, support enforcement, evaluation of the
effectiveness of certain employment and training programs and other purposes
authorized by law.
Failure to provide the required information may subject you to civil or criminal
penalties, or both, under the Tax Law.
This information is maintained by the Director of Records Management and Data
Entry, NYS Tax Department, W A Harriman Campus, Albany NY 12227; telephone 1
800 225-5829. From areas outside the United States and outside Canada, call (518)
485-6800.
Need Help?
Internet access: www.nystax.gov
(for information, forms, and publications)
Fax-on-demand forms: 1 800 748-3676
Telephone assistance is available from
8:00 A.M. to 5:00 P.M. (eastern time),
Monday through Friday. 1 800 698-2931
To order forms and publications: 1 800 462-8100
From areas outside the U.S. and outside Canada: [phone]
Hearing and speech impaired (telecommunications device for the
deaf (TDD) callers only): 1 800 634-2110
Persons with disabilities: In compliance with the Americans
with Disabilities Act, we will ensure that our lobbies, offices,
meeting rooms, and other facilities are accessible to persons
with disabilities. If you have questions about special
accommodations for persons with disabilities, please call 1 800
972-1233.