Vendor Number Request / Change Form - Monroe County

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Department of Human Services
Monroe County, New York
Maggie Brooks
Kelly A Reed
County Executive
Commissioner
VENDOR NUMBER REQUEST / CHANGE FORM
GENERAL COMPLETION INSTRUCTIONS:
o
Type or print clearly. NOTE: Provider of service must complete this form.
o
Include the Federal Tax ID and company name only if the payment is to be made to the company. If the payment is
to be made to you, as an individual, leave the company blank.
o
Attach a copy of your Social Security Card. If requesting a number for a company, please attach a copy of the
letter received from the IRS assigning the Tax ID to your company. No substitutions!
o
Return this page ONLY of completed forms to: Vendor Operations, PO BOX 23020, Rochester, NY, 14692
Only the original completed form with original signature is acceptable. No copies or faxes will be accepted.
o
Allow ten business days for processing. Once a number is assigned, this does not entitle you to payment. You must
contact the caseworker with any questions regarding payments.
o
Questions related to the completion of this form can be directed to 753-6663
Please check one:
Request NEW Number
Change existing information for Vendor # _____________________
*Effective date
Immediately
Other: __________________
Social Security or Tax ID # _______________________________________________________
Name_____________________________________________________________________________
Last
First
MI
Company or D.B.A.______________________________________________________________
Mailing Address_________________________________________________________________
Street / PO Box #
_____________________________________________________________________
City
State or Province
Zip
Phone Number___________________________Alternate Number_____________________________
What service will you be providing?
Day Care
Rental
Other: ______________________
I CERTIFY THAT THIS INFORMATION IS TRUE AND ACCURATE.
X______________________________________________________________________________________________
Signature
Date
OFFICE USE ONLY
NEW VENDOR NUMBER:___________________
Services
Non-Services
Case No. _____________________
Payment Type:
Rent
Day Care
Other:
Payment Code:
Caseworker: _______________ Unit ________ Number: ____________ Phone__________ Date:_______
Processed by______________ Date_____________

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