Taxpayer Identification Number (Tin) Verification
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1
2
3State of Montana
Department of Public Health
Department of Administration
and Human Services
SW9 (4/2009)
PO Box 4210
111 N Sanders
Helena, MT 59604
Phone: 406-444-5932
Send faxes to: 406-444-9763
W-9
Substitute
DO NOT send to IRS
Taxpayer Identification Number (TIN) Verification
Print or Type
Please see attachment or reverse for complete instructions.
Legal Name
Entity Designation
(check only one type)
(as entered with IRS) If Sole Proprietorship, enter your Last, First, MI
Corporation
S-Corp
C-Corp
Do you provide medical or legal services?
Trade Name
Yes
No
If doing business as (DBA) or enter business name of Sole Proprietorship
Individual
Sole Proprietorship
Primary Address
(for 1099 form)
Partnership
PO Box or Number and Street, City, State, ZIP + 4
General
Limited
LLC (for federal tax purposes taxed as)
Individual
Partnership
Corporation
Estate/Trust
Organization Exempt from Tax
Remit Address
(where payment should be mailed, if different from Primary
(under Section 501 (a)(b)(c)(d)(e))
Address) PO Box or Number and Street, City, State, ZIP + 4
Government Entity
Other_________________
Taxpayer Identification Number
TIN
(Provide Only One) (If sole proprietorship provide FEIN, if applicable)
(
)
Social Security Number
Federal Employer Identification No
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, 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.
3. I am a U.S. person (including a US resident alien).
Printed Name
Printed Title
Telephone Number
Signature
Date
Optional Direct Deposit Information (used at agency discretion) (all fields required to receive electronic payments)
(Must Include a Voided Check, No Direct Deposit Slips Accepted)
Your Bank Account Number
Checking
Name on Bank Account
Bank Routing No. (ABA)
Savings
THIS IS A:
New Direct Deposit
Change of Existing
Additional Direct Deposit
Email Change Only
Email Address (Please make this LEGIBLE)
If you provide bank information and an email address, we will send a message notifying you when an electronic payment is issued. We will
NOT share your email address with anyone or use it for any other purpose than communicating information about your electronic payments to
you. If you have questions about completing this form, please call the Warrant Writer Unit at 406-444-5932.
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