W-9/questionnaire For Non-Procurement Vendors Form Page 2

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Establish New Vendor

Establish Additional Remittance Address

Change Remittance Address

STATE OF NEW JERSEY

W-9/QUESTIONNAIRE FOR NON-PROCUREMENT VENDORS

THE STATE OF NEW JERSEY REQUIRES THE FOLLOWING INFORMATION TO ESTABLISH YOUR NAME, ADDRESS, AND TAXPAYER ID ON STATE RECORDS. THE

INFORMATION IS USED TO POPULATE AND MAINTAIN THE STATE’S VENDOR/PAYEE FILE AND MUST BE COMPLETED BEFORE PAYMENTS ARE MADE.

NOTE: PROCUREMENT VENDORS SHOULD NOT COMPLETE THIS FORM BUT SHOULD REGISTER AT NJSTART.GOV.

IMPORTANT: YOU WILL NOT BE PAID BY THE STATE OF NEW JERSEY UNTIL THIS FORM IS COMPLETED, SIGNED, AND

Return completed form to:

OMB VENDOR CONTROL

RETURNED. FOR ADDITIONAL INFORMATION CALL (609) 633-8183 OR EMAIL: AAIUNIT@TREAS.NJ.GOV.

PO BOX 221

TRENTON, NJ 08625 or

PART I.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

FAX: (609) 984-5210

Name (as shown on your tax return):

Doing business as (if different than name):

Address:

City:

State:

Zip:

If the above contains preprinted data that is incorrect, cross it out and write the correct information immediately next to it.

Taxpayer Identification Number (TIN) Enter your TIN below and check the type of number listed.

SOCIAL SECURITY NUMBER

EMPLOYER IDENTIFICATION NUMBER

Exemptions (codes apply only to certain entities, not individuals; see IRS Form W-9 instructions page 3):

Exempt payee code (if any) _________

Exemption from FATCA reporting code (if any) ___________

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 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

(3) I am a U.S. citizen or other US person as defined by the IRS.

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

of underreported interest or 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 IRA, and generally payments other than interest or dividends, you are not required

to sign the certification, but you must provide your correct TIN.

Sign

Signature

Date

Here

PART II

VENDOR/PAYEE DATA: STATE OF NEW JERSEY VENDOR/PAYEE INFORMATION QUESTIONNAIRE

NOTE: PROCUREMENT VENDORS SHOULD REGISTER AT NJSTART.GOV.

Enter the code from the list below that best describes your primary business function:

NON-PROCUREMENT PAYEES:

AC=AUTHORITY/COMMISSION

CF=CONFIDENTIAL FUND