"State of Nebraska Substitute Form W-9 & Ach Enrollment Form" - Nebraska

State of Nebraska Substitute Form W-9 & Ach Enrollment Form is a legal document that was released by the Nebraska Department of Education - a government authority operating within Nebraska.

Form Details:

  • Released on December 1, 2014;
  • The latest edition currently provided by the Nebraska Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Education.

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Download "State of Nebraska Substitute Form W-9 & Ach Enrollment Form" - Nebraska

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Clear Form
Return Form to the 
STATE OF NEBRASKA SUBSTITUTE FORM W-9 &
Requester. 
ACH ENROLLMENT FORM
 
(Rev.  December 2014) 
 
Requester Information:
(State of Nebraska Agency requesting this form to be completed)
Agency:
Phone:
Name:
Fax:
Address:
E-mail:
Substitute Form W-9:
(IRS Rev. December 2014)
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following boxes:
Individual
Sole proprietor
C Corporation
S Corporation
Partnership
Trust/Estate
Non-Profit Entity
Government (Local, State or Federal)
Limited Liability Company. Enter the tax classification (C = C Corporation, S = S Corporation, P = Partnership) ____
Other (see instructions) __________________________
Note: Enter the owner’s name on line 1 and mark the appropriate federal tax classification box for disregarded entities.
4 Exemptions (see instructions): Exempt payee code (if any) _____
Exemption from FATCA reporting code (if any) ___________
5 Address:
Remit Address (if different):
6 City, state, and ZIP code
City, state, and ZIP code
Taxpayer Identification Number (TIN):
Social Security Number (SSN):
OR
Employer Identification Number (EIN):
_________-______-____________
______-_____________________
Certification:
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding due to failure to report interest and dividend income, and
3. I am a U.S. citizen or other U.S. person (defined in the instructions), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
For additional instructions please refer to http://www.irs.gov/pub/irs-pdf/fw9.pdf to obtain a copy of the IRS Form W-9 General Instructions.
 
Signature of US Person:
Date:
Printed Name:
Contact Phone:
Comments or Business/Entity Notes:
ACH Enrollment:
Initial Setup
Change
Close Account
(Rev. December 2014)
This information is REQUIRED to process ACH payments. Without this information, your payment may be delayed.
Check here if the bank is outside of 
Financial Institution Name:
Nine Digit Routing Number:
Prior Routing Number: *
the United States.
Check here if our payments to you 
Address:
Depositor Account Number:
Prior Account Number: *
are being forwarded from a U.S. 
financial institution to a financial 
institution in another country
City, state and ZIP code:
Type of Account:
* Prior ACH instructions are required to be completed if
changing/updating your ACH instructions with the State of
Checking
Savings
Nebraska.
This account will be used for all payments by the State of Nebraska unless specified here: _________________________________
E-mail:_______________________________________________
(Used for ACH payment notifications.)
Authorized Individual
Attachment Required!
or Entity Signature:
(Select and attach one of the following items for verification):
Printed Name:
Blank check (voided) or
Photocopy of a cleared check
Title:
Letter or statement from your financial institution
Date
Vendor invoice or letter which contains printed ACH instructions
Internal Use Only:
Clear Form
Return Form to the 
STATE OF NEBRASKA SUBSTITUTE FORM W-9 &
Requester. 
ACH ENROLLMENT FORM
 
(Rev.  December 2014) 
 
Requester Information:
(State of Nebraska Agency requesting this form to be completed)
Agency:
Phone:
Name:
Fax:
Address:
E-mail:
Substitute Form W-9:
(IRS Rev. December 2014)
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following boxes:
Individual
Sole proprietor
C Corporation
S Corporation
Partnership
Trust/Estate
Non-Profit Entity
Government (Local, State or Federal)
Limited Liability Company. Enter the tax classification (C = C Corporation, S = S Corporation, P = Partnership) ____
Other (see instructions) __________________________
Note: Enter the owner’s name on line 1 and mark the appropriate federal tax classification box for disregarded entities.
4 Exemptions (see instructions): Exempt payee code (if any) _____
Exemption from FATCA reporting code (if any) ___________
5 Address:
Remit Address (if different):
6 City, state, and ZIP code
City, state, and ZIP code
Taxpayer Identification Number (TIN):
Social Security Number (SSN):
OR
Employer Identification Number (EIN):
_________-______-____________
______-_____________________
Certification:
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding due to failure to report interest and dividend income, and
3. I am a U.S. citizen or other U.S. person (defined in the instructions), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
For additional instructions please refer to http://www.irs.gov/pub/irs-pdf/fw9.pdf to obtain a copy of the IRS Form W-9 General Instructions.
 
Signature of US Person:
Date:
Printed Name:
Contact Phone:
Comments or Business/Entity Notes:
ACH Enrollment:
Initial Setup
Change
Close Account
(Rev. December 2014)
This information is REQUIRED to process ACH payments. Without this information, your payment may be delayed.
Check here if the bank is outside of 
Financial Institution Name:
Nine Digit Routing Number:
Prior Routing Number: *
the United States.
Check here if our payments to you 
Address:
Depositor Account Number:
Prior Account Number: *
are being forwarded from a U.S. 
financial institution to a financial 
institution in another country
City, state and ZIP code:
Type of Account:
* Prior ACH instructions are required to be completed if
changing/updating your ACH instructions with the State of
Checking
Savings
Nebraska.
This account will be used for all payments by the State of Nebraska unless specified here: _________________________________
E-mail:_______________________________________________
(Used for ACH payment notifications.)
Authorized Individual
Attachment Required!
or Entity Signature:
(Select and attach one of the following items for verification):
Printed Name:
Blank check (voided) or
Photocopy of a cleared check
Title:
Letter or statement from your financial institution
Date
Vendor invoice or letter which contains printed ACH instructions
Internal Use Only: