Vendor Tax Information Form - Florida Polytechnic University Page 2

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Will Florida Poly provide supplies, equipment, materials, or tools to accomplish the work/service? ____No ____Yes (Please describe.)

______________________________________________________________________________________________________________________

Do you perform similar work/service for others? ____No ____Yes

Will you be reimbursed for any expenses that you incur while performing the proposed work/service? ____No ____Yes (Please describe.)

______________________________________________________________________________________________________________________

Part 6

– Certification:

Under penalties of perjury, I certify that:

1. The taxpayer identification number provided on this form is correct (or I am waiting for a TIN 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 failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer

subject to backup withholding.

3. I am a U.S. Person (including a U.S. resident alien).

As a vendor performing service for Florida Polytechnic University, I understand that I am not covered under the State of Florida Worker's

Compensation Law (F.S. 440) and it is my responsibility to obtain personal liability insurance. I am also aware that all taxes attributable to any service

that I render to Florida Polytechnic University are my responsibility.

Signature of U.S. Person (Payee)

Phone

Date

ANY TAXES, INTEREST OR PENALTIES ASSESSED AGAINST FLORIDA POLYTECHNIC UNIVERSITY BY THE IRS DUE TO MISCLASSIFICATION OF

AN INDIVIDUAL AS AN INDEPENDENT CONTRACTOR WILL BE PAID BY THE DEPARTMENT AUTHORIZING THE CONTRACTUAL RELATIONSHIP.

Florida Polytechnic Department

Florida Polytechnic Director, Vice-President, Name or Designee

Signature

Date

Once completed, please return to the Florida Polytechnic department you are currently working with. The department will be responsible for

obtaining the appropriate signature of their department chair, director or Vice-President and submitting the form to Vendor Maintenance.