Substitute Form
REQUEST FOR TAXPAYER IDENTIFICATION
W-9
State of Montana
NUMBER (TIN) VERIFICATION
Do NOT send to IRS
PRINT OR TYPE
RETURN TO ADDRESS BELOW
Legal Name
(OWNER OF THE EIN OR SSN AS APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS) DO
NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE-See Reverse for Important Information
Trade Name
COMPLETE ONLY IF DOING BUSINESS AS (DBA)
Remit Address
Purchase Order Address – Optional
PART II
See Part II Instruction on Back of Form
Check legal entity type and enter 9 digit Taxpayer Identification Number (TIN) below:
Do Not enter an SSN or EIN that was not
assigned to the legal name entered above
(SSN = Social Security Number EIN = Employer Identification Number)
Individual
(Individual’s SSN)
NOTE: If no name is circled on a Joint Account when there is more then one name, the number will be considered to be that of the first name listed.
Sole Proprietorship (Owner’s SSN or Business FEIN)
SSN
NOTE: Enter both the owner’s SSN and the Business EIN (if you are required to have one)
EIN
EFFECTIVE DATE OF EIN
Partnership
(Partnership’s EIN)
General
Limited
EFFECTIVE DATE OF EIN
Estate / Trust
(Legal Entity’s EIN)
NOTE: Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in
the account title. List and circle the name of the legal trust, estate or pension trust.
EFFECTIVE DATE OF EIN
Other
(Entity’s EIN)
Please specify
Limited Liability Company, Joint Venture, Club, etc.
EFFECTIVE DATE OF EIN
Corporation
(Corp’s EIN)
Do you provide legal or medical services?
Yes
No
Includes corporations providing medical billing services
EFFECTIVE DATE OF EIN
Government
(Entity’s EIN)
(or Government Operated) Entity
EFFECTIVE DATE OF EIN
Organization
(Org’s EIN)
Exempt from Tax under Section 501(a)
Do you provide medical services?
Yes
No
EFFECTIVE DATE OF EIN
Check here if you do not have a SSN or EIN, but have applied for one. See reverse for information on How to Obtain a TIN.
Licensed Real Estate Broker?
Yes
No
Exempt from backup withholding?
Yes
No
Under Penalties of perjury, I certify that:
1.
The number listed 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 (does not apply to real estate transactions, mortgage interest paid, the acquisition of abandonment of secured
property, contribution to an individual retirement arrangement (IRA), and payments other than interest and dividends).
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 of under reporting interest or dividends on your tax return. (See Signing the Certification on the reverse of this form.)
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS
DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING
Name (Print or Type)
Title (Print or Type)
Signature of U.S. Person
Date
Phone(
)
E-Mail Address (Print or Type)
DO NOT WRITE BELOW THIS LINE
RETURN TO ADDRESS ABOVE
AGENCY USE ONLY
Agency
Approved By
Date
1099
Yes
No
Vendor
Addition
Change
Action Completed By
Date
615-82-50-7093 (R 2/06)
Substitute Form
REQUEST FOR TAXPAYER IDENTIFICATION
W-9
State of Montana
NUMBER (TIN) VERIFICATION
Do NOT send to IRS
PRINT OR TYPE
RETURN TO ADDRESS BELOW
Legal Name
(OWNER OF THE EIN OR SSN AS APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS) DO
NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE-See Reverse for Important Information
Trade Name
COMPLETE ONLY IF DOING BUSINESS AS (DBA)
Remit Address
Purchase Order Address – Optional
PART II
See Part II Instruction on Back of Form
Check legal entity type and enter 9 digit Taxpayer Identification Number (TIN) below:
Do Not enter an SSN or EIN that was not
assigned to the legal name entered above
(SSN = Social Security Number EIN = Employer Identification Number)
Individual
(Individual’s SSN)
NOTE: If no name is circled on a Joint Account when there is more then one name, the number will be considered to be that of the first name listed.
Sole Proprietorship (Owner’s SSN or Business FEIN)
SSN
NOTE: Enter both the owner’s SSN and the Business EIN (if you are required to have one)
EIN
EFFECTIVE DATE OF EIN
Partnership
(Partnership’s EIN)
General
Limited
EFFECTIVE DATE OF EIN
Estate / Trust
(Legal Entity’s EIN)
NOTE: Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in
the account title. List and circle the name of the legal trust, estate or pension trust.
EFFECTIVE DATE OF EIN
Other
(Entity’s EIN)
Please specify
Limited Liability Company, Joint Venture, Club, etc.
EFFECTIVE DATE OF EIN
Corporation
(Corp’s EIN)
Do you provide legal or medical services?
Yes
No
Includes corporations providing medical billing services
EFFECTIVE DATE OF EIN
Government
(Entity’s EIN)
(or Government Operated) Entity
EFFECTIVE DATE OF EIN
Organization
(Org’s EIN)
Exempt from Tax under Section 501(a)
Do you provide medical services?
Yes
No
EFFECTIVE DATE OF EIN
Check here if you do not have a SSN or EIN, but have applied for one. See reverse for information on How to Obtain a TIN.
Licensed Real Estate Broker?
Yes
No
Exempt from backup withholding?
Yes
No
Under Penalties of perjury, I certify that:
1.
The number listed 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 (does not apply to real estate transactions, mortgage interest paid, the acquisition of abandonment of secured
property, contribution to an individual retirement arrangement (IRA), and payments other than interest and dividends).
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 of under reporting interest or dividends on your tax return. (See Signing the Certification on the reverse of this form.)
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS
DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING
Name (Print or Type)
Title (Print or Type)
Signature of U.S. Person
Date
Phone(
)
E-Mail Address (Print or Type)
DO NOT WRITE BELOW THIS LINE
RETURN TO ADDRESS ABOVE
AGENCY USE ONLY
Agency
Approved By
Date
1099
Yes
No
Vendor
Addition
Change
Action Completed By
Date
615-82-50-7093 (R 2/06)
NAME AND TAX IDENTIFICATION NUMBER (TIN)
INDIVIDUALS:
Enter First and Last name EXACTLY as it appears on your Social Security Card. However, if you have changed your last
name, for instance, due to marriage, without informing the Social Security Administration of the name change, please enter your first name
and both the last name shown on your social security card and your new last name (IN THAT ORDER). For your TIN, enter your Social
Security Number (SSN).
SOLE PROPRIETORSHIPS:
Enter the owner’s name on the first line; on the second name line you may enter the business name. YOU
MAY NOT ENTER ONLY THE BUSINESS NAME. For the TIN, enter both the owner’s Social Security Number and the Federal Employer Tax
Identification Number (EIN) if you are required to have one.
ALL OTHER ENTITIES:
Enter the name of the owner of the EIN or SSN exactly as originally registered with the IRS. The correct TIN is
the Employer Identification Number (EIN).
DO NOT ENTER AN SSN OR EIN THAT WAS NOT ASSIGNED TO THE
LEGAL NAME OF THIS FORM
HOW TO OBTAIN A TIN
If you do not have a TIN, you should apply for one immediately. To apply for the number, obtain Form SS-05, Application for a Social Security Number
Card (for individuals), or Form SS-4, Application of Employer Identification number (for businesses and all other entities), at your local office of the Social
Security Administration or the Internal Revenue Service. Complete and file the appropriate form according to its instructions.
To complete Form W-9 if you do not have a TIN, check “Applied For” box in the space indicated on the front, sign and date the form, and give it to the
requester. For payments that could be subject to backup withholding, you will then have 60 days to obtain a TIN and furnish it to the requester. During the
60-day period, the payments you receive will not be subject to the 31% backup withholding, unless you make a withdrawal. However, if the requester does
not receive your TIN from you within 60 days, backup withholding, if applicable, will begin and continue until you furnish your TIN to the requester.
NOTE: Writing “Applied For” on the form means that you have already applied for a TIN OR that you intend to apply for one in the near future.
As soon as you receive your TIN, complete another Form W-9, include your new TIN, sign and date the form, and give it to the requester.
FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING
Individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for
certain payments, such as interest and dividends.
If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter your
correct TIN in Part I, write ‘Exempt’ in Part II and sign and date the form.
If you are a nonresident alien or foreign entity not subject to backup withholding, give the requester a completed Form W-8, Certificate of
Foreign Status.
+
CERTIFICATION
1) Interest, Dividend, and Barter Exchange Accounts Opened Before 1984 and Broker Accounts That Were
Considered Active During 1983.
– You are not required to sign the certification; however, you may do so. You are required to provide
your correct TIN.
(2) Interest, Dividend, Broker and Barter Exchange Accounts Opened After 1983 and Broker Accounts That
Were Considered Inactive During 1983.
– You must sign the certification or backup withholding will apply. If you are subject to
backup withholding and you are merely providing your correct TIN to the requester, you must cross out item (2) in the certification before
signing the form.
(3) Real Estate Transactions
– You must sign the certification. You may cross out item (2) of the certification if you wish.
(4) Other Payments
– You are required to furnish your correct TIN, but you are not required to sign the certification unless you have
been notified of an incorrect TIN. Other payments include payments made in the course of the requester’s trade or business for rents,
royalties, goods (other than bills for merchandise), medical and heath care services, payments to a nonemployee for services (including
attorney and accounting fees), and payments to certain fishing boat crew members.
(5) Mortgage Interest Paid by You, Acquisition or Abandonment of Secured Property, or IRA Contributions.
You are required to furnish your correct TIN, but not required to sign the certification.
Signature.
– The signature should be an authorized signature, generally the person whose name is on the top line of the form, a partner
in the partnership, or an officer of the corporation. For joint account, only the person whose TIN is shown in LEGAL
BUSINESS DESIGNATION should sign the form.
Privacy Act Notice.
– Section 6109 requires you to furnish your correct taxpayer identification number (TIN) to persons who must file
information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the
acquisition or abandonment of secured property, or contributions you made to an individual retirement arrangement (IRA). IRS uses the
numbers for identification purposes and to help verify accuracy of your tax return. You must provide your TIN whether or not you are
required to file a tax return. Payers must generally withhold 31% of taxable interest, dividend, and certain other payments to a payee who does
not furnish a TIN to a payer. Certain other penalties may also apply.
ADVERTISEMENT