Substitute For Form W-9 - Request For Taxpayer Id Number And Certification
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1SUBSTITUTE FOR FORM W-9
REQUEST FOR TAXPAYER ID NUMBER AND CERTIFICATION
Pursuant to Internal Revenue Service Regulations, you must furnish your Taxpayer Identification Number (TIN) to the
County of Brunswick. If this number is not provided, you may be subject to a 31% withholding on each payment. To
avoid this 31% withholding and to insure that accurate tax information is reported to the Internal Revenue Service, please
use this form to provide the requested information.
OWNER’S NAME
____________________________________________________________________
Note: If you are a sole proprietor the above line must be completed with
your name as shown on your SOCIAL SECURITY CARD.
LEGAL BUSINESS NAME
____________________________________________________________________
Note: If you are a sole proprietor your legal business name should be your
“doing business as” or “trading as” name.
____________________________________________________________________
Mailing Address
City
State&Zip
Phone: ___________________________ Fax: ______________________
Email address :________________________________________________
Business Type (check one)
Business Activity (check one)
□ Corporation
□ Government Agency
□ Services Only
□ Legal Services
□ Partnership
□ Trust or Estate
□ Merchandise (goods only)
□ Medical/Health Care
□ Sole Proprietorship/Individual
□ Merchandise & Services
□ Real Estate Rent/Lease
□ Tax Exempt or Non-Profit Organization
CERTIFICATION:
Under penalties of perjury, I certify that:
1.
The legal name and number shown on this confirmation letter is my correct legal name and 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 that I am subject to backup withholding as a result of failure to
report all interest or dividends, or (c) the Internal Revenue Service has notified me that I am no longer subject
to backup withholding.
OR
FEDERAL TAX IDENTIFICATION NUMBER
SOCIAL SECURITY NUMBER
□□-□□□□□□□
□□□-□□-□□□□
NOTE: If you are a sole proprietor you may use either your SSN or FIN, as your Taxpayer Identification Number. If you
are a corporation, partnership, government entity, trust or estate, tax exempt or non-profit organization you must provide a
FIN as your Taxpayer Identification Number.
Authorized Signature
Printed Name
Date
♦♦♦♦♦♦♦♦♦♦♦♦♦♦
PROOF OF INSURANCE (required for all non-incorporated vendors only)
____is attached
_____will be sent within 10 days
If you do not have general liability and/or workers compensation insurance please explain:
_______________________________________________________________________________
PLEASE RETURN FORM TO:
County of Brunswick, Finance Department
FAX: 434-848-0918
228 N Main St Ste 101, Lawrenceville VA 23868
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Parent category: Financial