Fillable State Of Nebraska Substitute Form W-9 & Ach Enrollment Form

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Return Form to the

STATE OF NEBRASKA SUBSTITUTE FORM W-9 &

Requester.

ACH ENROLLMENT FORM

(Rev. December 2014)

Requester Information:

(State of Nebraska Agency requesting this form to be completed)

Agency:

Phone:

Name:

Fax:

Address:

E-mail:

Substitute Form W-9:

(IRS Rev. December 2014)

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following boxes:

Individual

Sole proprietor

C Corporation

S Corporation

Partnership

Trust/Estate

Non-Profit Entity

Government (Local, State or Federal)

Limited Liability Company. Enter the tax classification (C = C Corporation, S = S Corporation, P = Partnership) ____

Other (see instructions) __________________________

Note: Enter the owner’s name on line 1 and mark the appropriate federal tax classification box for disregarded entities.

4 Exemptions (see instructions): Exempt payee code (if any) _____

Exemption from FATCA reporting code (if any) ___________

5 Address:

Remit Address (if different):

6 City, state, and ZIP code

City, state, and ZIP code

Taxpayer Identification Number (TIN):

Social Security Number (SSN):

Employer Identification Number (EIN):

_________-______-____________

______-_____________________

Certification:

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 due to failure to report interest and dividend income, and

3. I am a U.S. citizen or other U.S. person (defined in the instructions), and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

For additional instructions please refer to to obtain a copy of the IRS Form W-9 General Instructions.

Signature of US Person:

Date:

Printed Name:

Contact Phone:

Comments or Business/Entity Notes:

ACH Enrollment:

Initial Setup

Change

Close Account

(Rev. December 2014)

This information is REQUIRED to process ACH payments. Without this information, your payment may be delayed.

Check here if the bank is outside of

Financial Institution Name:

Nine Digit Routing Number:

Prior Routing Number: *

the United States.

Check here if our payments to you

Address:

Depositor Account Number:

Prior Account Number: *

are being forwarded from a U.S.

financial institution to a financial

institution in another country

City, state and ZIP code:

Type of Account:

* Prior ACH instructions are required to be completed if

changing/updating your ACH instructions with the State of

Checking

Savings

Nebraska.

This account will be used for all payments by the State of Nebraska unless specified here: _________________________________

E-mail:_______________________________________________

(Used for ACH payment notifications.)

Authorized Individual

Attachment Required!

or Entity Signature:

(Select and attach one of the following items for verification):

Printed Name:

Blank check (voided) or

Photocopy of a cleared check

Title:

Letter or statement from your financial institution

Date

Vendor invoice or letter which contains printed ACH instructions

Internal Use Only:

State Of Nebraska Substitute Form W-9 & Ach Enrollment Form - 2014

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