New Vendor Authorization Form/substitute For Irs Form W-9
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1Vendor Number:________________
Elbert County School District
Attn: Ben M. Childs, CFO
50 Laurel Drive
Elberton, Georgia 30635
Telephone (706) 213-4000 / FAX (706) 283-6674
New Vendor Authorization Form/Substitute for IRS Form W-9
In order to comply with Internal Revenue Service (IRS) regulations, we are required to obtain your Social Security No
(SSN) or the Federal Tax ID Number (TIN) to satisfy Form 1099 reporting requirements. Failure to provide this
information may subject all payments to you to the 31% backup withholding as required by the IRS. The District offers the
option to receive your payments via ACH transfer. If so desired, please provide your routing number and bank account
number on company or bank letterhead along with an email address to receive verification of payments. Please return
form with your BID / RFP if this is bid related.
Name:
___________________________________________________________________________________________
(Please Print as reported on income tax return)
Check Appropriate Blank:
If you or your firm is performing services or supplying more than
___ Individual/Sole Proprietor
$10,000 in goods and materials, a copy of your insurance certificate
___ Partnership
showing workers compensation and general liability must be attached.
___ Corporation
By not attaching, payment maybe delayed and you may be subject to an
___ Other (specify) ________________
estimated workers compensation adjustment if you are providing
___Employee of the District
services.
Order Address: ____________________________________________________________________________________
Address ➀
___________________________________________________________________________________
Address ➁
___________________________________________________________________________________
City/State
__________________________________________Zip Code_________________________________
Telephone#:
_____________________________________
FAX# _______________________________
Email Address:
__________________________________________________________________________________
Preferred Method to Receive Purchase Orders
Mail_____________ Fax______________ Email ______________
REMIT TO ADDRESS
(If different from Order Address)
Address: _______________________________________________________________________________________
Telephone#:
_____________________________________
FAX# _______________________________
SOCIAL SECURITY NUMBER
Enter your TIN in the appropriate box. For individuals, this is
__________ -_______-__________
your Social Security Number. For Sole proprietors you must
use your SSN. For partnerships you must show the name
EMPLOYER ID NUMBER
filed first on partnership papers. For other entities, it is your
Employer Identification Number.
_______-_____________________
E Verify # _____________
Certification:
I certify that (1) I am a US person and duly authorized to complete this form; (2) the legal organization and Tax
Identification Number shown on this form are correct and (3) I am not subject to backup withholding. I further certify that I
nor my firm has been debarred from conducting business with any federal, state or local government agency.
Signature: ________________________________________________
Date: _______________________
Title:
________________________________________________
The IRS requires an original signature.
Type of products/ description of services offered:________________________________________________________
_______________________________________________________________________________________________
Date Received by the District: ____________________ Approved by:_____________ Entered By:_____________
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