Division of Finance
STATE OF ALASKA
PO Box 110204
Telephone: (907) 465-5599
Juneau, AK 99811-0204
Department of Administration
Return FAX: (907) 465-5639
SUBSTITUTE FORM W-9
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER
Beneficiary of Deceased Employee
The Internal Revenue Service requires that at the end of each year, the State of Alaska prepare IRS 1099 forms. When the
total of all payments for the year meet or exceed $600.00 and are made to individuals for rents, services, prizes, beneficiary
payments and awards, we will generate the required Form 1099 using the information provided below.
I N S T R U C T I O N S
Please provide the requested information, complete and sign the certification below. This information must match the
information you provide to the Internal Revenue Service for Tax Reporting. Federal Law requires us to take backup
withholding from future payments made if you fail to complete and sign the certification. Mail or fax the completed form to
the Division of Finance.
Deceased Name:
B E N E F I C I A R Y I N F O R M A T I O N
P L E A S E P R I N T O R T Y P E A L L I N F O R M A T I O N C L E A R L Y
Beneficiary Name:
SSN:
Address:
City:
State:
ZIP+4:
C E R T I F I C A T I O N
REQUIRED INTERNAL REVENUE SERVICE STATEMENT
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding. 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 because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to
report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return.
Printed Name:
Date:
Signature:
Telephone:
Fax:
W E W I L L P R O V I D E T H E I N S T R U C T I O N S F O R T H E F O R M W - 9 O N R E Q U E S T .
REVISED 05-20-2009
Division of Finance
STATE OF ALASKA
PO Box 110204
Telephone: (907) 465-5599
Juneau, AK 99811-0204
Department of Administration
Return FAX: (907) 465-5639
SUBSTITUTE FORM W-9
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER
Beneficiary of Deceased Employee
The Internal Revenue Service requires that at the end of each year, the State of Alaska prepare IRS 1099 forms. When the
total of all payments for the year meet or exceed $600.00 and are made to individuals for rents, services, prizes, beneficiary
payments and awards, we will generate the required Form 1099 using the information provided below.
I N S T R U C T I O N S
Please provide the requested information, complete and sign the certification below. This information must match the
information you provide to the Internal Revenue Service for Tax Reporting. Federal Law requires us to take backup
withholding from future payments made if you fail to complete and sign the certification. Mail or fax the completed form to
the Division of Finance.
Deceased Name:
B E N E F I C I A R Y I N F O R M A T I O N
P L E A S E P R I N T O R T Y P E A L L I N F O R M A T I O N C L E A R L Y
Beneficiary Name:
SSN:
Address:
City:
State:
ZIP+4:
C E R T I F I C A T I O N
REQUIRED INTERNAL REVENUE SERVICE STATEMENT
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding. 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 because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to
report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return.
Printed Name:
Date:
Signature:
Telephone:
Fax:
W E W I L L P R O V I D E T H E I N S T R U C T I O N S F O R T H E F O R M W - 9 O N R E Q U E S T .
REVISED 05-20-2009
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