Form Doa-6448 (Substitute W-9) - Taxpayer Identification Number (Tin) Verification - State Of Wisconsin Department Of Administration
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3State of Wisconsin
Division of Executive Budget and Finance
Department of Administration
State Controller’s Office
DOA-6448 (R09/2004)
W-9
Substitute
DO NOT send to IRS
Taxpayer Identification Number (TIN) Verification
Print or Type
Please see attachment or reverse for complete instructions.
This form can be made available in alternative formats to qualified individuals upon request.
Legal Name
(as entered with IRS)
Entity Designation
Required
(check only one)
If Sole Proprietorship or LLC Single Owner, enter your Last, First, MI
Individual/Sole Proprietor/LLC Single Owner
Corporation (includes service corporations)
Limited Liability Company - Partnership
Trade Name
Limited Liability Company - Corporation
Enter Business Name if different from above.
Government Entity
Hospital Exempt from Tax or Government
Owned
Remit Address
(where check should be mailed)
Long Term Care Facility Exempt from Tax or
PO Box or Number and Street, City, State, ZIP + 4
Government Owned
All Other Entities
Taxpayer Identification Number (TIN)
If you are a sole proprietor and you have an EIN,
you may enter either your SSN or EIN. However,
the IRS prefers that you show the SSN.
Order Address
(where order should be mailed; complete only if different from remit)
PO Box or number and street, City, State, ZIP + 4
___ ___ ___ ___ ___ ___ ___ ___ ___
1099 Address
Required
Check Only One
(see “Instructions”)
(for return of 1099 form; complete only if different from remit)
PO Box or number and street, City, State, ZIP + 4
Social Security Number (SSN)
Employer Identification Number (EIN)
Individual Taxpayer Identification Number
for U.S. Resident Aliens (ITIN)
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, AND
I am not subject to back up withholding because (a) I am exempt from backup withholding, or (b) I have not been
2.
notified by the Internal Revenue Service (IRS) that I am subject to back up 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.
3. I am a U.S. person (including a US resident alien).
Printed Name
Printed Title
Telephone Number
(
)
Signature
Date
(mm/dd/ccyy)
For Agency Use Only
Agency Number
Contact
Phone Number
Change
Name
Address
Other (explain)
Return completed form via facsimile machine or to the address listed below.
For your convenience this form has been designed for return in a standard Window envelope.
Forms may be returned to:
Fax Number: (
)
Attn:
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