Application For An "Isp" Independent Service Provider & Irs Form W-9 & Njs Verification Form (Page 2 of 3) in pdf

W-9

Request for Taxpayer Identification

Give Form to the

IRS FORM

requester. Do not

NJS

send to the IRS.

Number and Certification

Verification Form

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

4 Exemptions (codes apply only to

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

certain entities, not individuals; see



instructions on page 3 instructions)

Individual/sole proprietor or

C Corporation

S Corporation

Partnership

Trust/estate

single-member LLC

Exempt payee code (if any)



▶ __________

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Exemption from FATCA reporting code

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for

(if any)

the tax classification of the single-member owner.

5 Address (number, street, and apt. or suite no.)

Requester’s name and address (optional)

Expert Janitorial, LLC d.b.a.

6 City, state, and ZIP code

National Janitorial Solutions

14000 Commerce Parkway, Suite D

Mount Laurel, New Jersey 08054

Part I

Taxpayer Identification Number (TIN)

Social security number

Enter your TIN in appropriate box. The TIN provided must match the name given on line 1 to avoid backup

withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole

–

proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer

identification number (EIN).:

Employer identification number

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines

on whose number to enter. Instructions are found: https:// /uac/about-form-w9.

–

Part II

Certification

Under penalties of perjury, I certify that:

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

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; and

I am a U.S. citizen or other U.S. person (defined below); and

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

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

you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition

or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than

interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.

https:// /uac/about-form-w9

Sign

Signature of

Here

Verification & Penalties

Part III

NJS Verification: By executing and submitting this form, I understand a verification of information process may be initiated by Ex pert Janitorial, LLC (“NJS”) including

Tax Identification Number, State Business License status, open public records and/or obtaining information from the federal registry database(s).

IRS Penalties - Failure to furnish TIN

If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Part IV

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with

the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation

of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the

IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the

District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a

treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your

TIN whether or not you are required to file a tax return. Certain penalties may also apply for providing false or fraudulent information.

IRS Form W-9 (Rev. 12-2014) – NJS Verification Form (Rev. 09-2016)