Substitute W-9 Form - Employee and Family …



Substitute W-9 Form

Request for Taxpayer Identification Number and Certification

Complete sections A through D and return to Employee & Family Resources

A. General Information

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|*Taxpayer Name ___________________________________________________________________________________________________ |

|∙ Must exactly match Name on Federal Income Tax Return. ∙ EFR Checks will be made payable to Taxpayer Name |

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|Business Name (If different from above Taxpayer Name) |

|_________________________________________________________________________________________________________________ |

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|Address |

|_________________________________________________________________________________________________________________ |

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|City, State, Zip ____________________________________________________________________________________________________ |

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|* This should be the registered name the IRS has on file for the tax ID entered below. Do not abbreviate the registered name. If the tax ID number |

|entered below is your social security number, please list your complete individual name as it appears on your social security card as taxpayer name. |

B. Check (√) the most appropriate category below: (please select only one)

|# 1 |# 2 |# 3 |# 4 |# 5 |# 6 |# 7 |

|INDIVIDUAL |SOLE PRO-PRIETORSHIP |SOLE PROPRIETORSHIP |CORPORATION |PARTNERSHIP |LIMITED |GOVERNMENT AGENCIES |

|(On the Taxpayer |(On the Taxpayer Name |(using a federal employer |(Enter your business|(Enter your business|LIABILITY |AND ORGANI-ZATIONS |

|Name line of this|line of this form, |identification number for taxpayer ID|name on the Taxpayer|name on the Taxpayer|COMPANY |THAT ARE TAX-EXEMPT |

|form, enter your |enter your INDIVIDUAL |or SINGLE-OWNER LIMITED LIABILITY |Name line. Provide |Name line. Provide |That is a |under Internal |

|INDIVIDUAL name |name as shown on your |COMPANY that is disregarded as an |your Employer ID |your Employee ID |corporation |Revenue Service |

|as shown on your |social security card. |entity separate from its owner. |Number below.) |Number below.) |partnership, |guidelines (i.e. IRC|

|social security |Provide your Social | | | |etc. (Enter |501(c)3 entities) |

|card. Provide |Security Number |(On the Taxpayer Name line of this | | |your business | |

|your Social |below.) You may enter|form, enter your INDIVIDUAL name as | | |name on the | |

|Security Number |your business as [DBA]|shown on your social security card. | | |Taxpayer Name | |

|below.) |name on the “Business |Provide your Employer Identification | | |line. Provide | |

| |Name” line.) |Number below.) You may enter your | | |your Employer | |

| | |business as “doing business as” | | |ID Number | |

| | |[DBA] name on the “Business Name” | | |below.) | |

| | |line.) | | | | |

C. Fill in your taxpayer identification number below: (please complete only one)

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|If you checked number 1 or 2 above, fill in your Social Security Number. |

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|Social Security Number______________________________________________________________________________________________ |

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|If you checked on of the number 3-7 above, fill in your Federal Employer Identification Number (EIN) |

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|Federal EIN Number ________________________________________________________________________________________________ |

D. Sign and date the form:

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|Certification. Under penalties of perjury, I certify that the information shown on this form is correct to my knowledge. |

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|Signature ______________________________________________________________ Date ________________________________________ |

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|Title __________________________________________________________________ Phone Number ________________________________ |

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