Form 23743 - Taxpayer Identification Number Request

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Taxpayer Identification Number Request
Subsititute Form
State Form 23743 (R 07\01)
State of Indiana
Approved by State Board of Accounts 2001
Approved by Auditor of State 2001
W-9
DO NOT send to IRS
Return to address below
Print or Type
(OWNER OF THE EIN OR SSN AS NAME APPEARS ON IRS OR SSN RECORDS)
Legal Name
DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE
Trade Name
Complete only if doing business as (D/B/A)
Remit Address
Purchase Order Address-Optional
Check legal entity type and enter 9 digit taxpayer identification Number (TIN) below:
SSN or EIN must be for
(SSN = Social Security Number, EIN = Employer Identification Number)
legal name above
Individual
__ __ __-__ __-__ __ __ __
(Individual's SSN)
Sole Proprietorship
(Owner's SSN or Business EIN)
SSN
__ __ __-__ __-__ __ __ __
__ __-__ __ __ __ __ __ __
EIN
__ __-__ __ __ __ __ __ __
Partnership
General
Limited
(Partnership's EIN)
__ __-__ __ __ __ __ __ __
Estate/Trust
(Legal Entity's EIN)
Note: Show the name and number of legal trust, or estate, not personal representatives
__ __-__ __ __ __ __ __ __
Other
(Limited Liability Company, Joint Venture, Club, ect)
(Legal Entity's EIN)
__ __-__ __ __ __ __ __ __
Corporation
Do you provide legal or medical serv.
Yes
No
(Corp's EIN)
Governement (or Government operated entity)
(Entity's EIN)
__ __- __ __ __ __ __ __ __
Organization Exempt from Tax under Section 501(a)
Do you provide medical services?
__ __-__ __ __ __ __ __ __
Yes
No
(Org's EIN)
Check here if you do not have a SSN or EIN but have applied for one.
Under Penalties of prejury, I certify that:
(1) The number listed 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 the 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 (does not apply to real estate transactions, mortgage interest paid, and acquisition
or abandonment of secured property, contribution to an indivual retirement arrangement (IRA), and payments other than interest and dividends.)
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 underreporting interest or dividends on your tax return.
THE IRS DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE
CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.
I am a U.S. person (including a U.S. resident alien)
Name (Print or Type)
Title
AUTHORIZED SIGNATURE
Date
Phone
Agency
Yes
Agency use only
No Approved by
1099
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

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