Request For Taxpayer Identification Number

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STATE OF ALABAMA
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER
STATE COMPTROLLER’S OFFICE
INSTRUCTIONS: In order to receive payment by the State of Alabama, a correct tax identification
number, name and address must be on our files.
Payments will be or were made to you by an agency
or department of the State of Alabama.
To insure that accurate tax information is reported on Form
1099 for federal income tax purposes, please:
1.
In PART 1 below provide your Tax Identification Number and check FEIN or SSN.
Also provide
name and address to which payment should be sent.
2.
Circle the business designation that identifies your type of trade or business in Part 2.
3.
Return this form as soon as possible to:
DEPARTMENT OF CONSERVATION & NATURAL RESOURCES
64 NORTH UNION STREET - ROOM
MONTGOMERY, ALABAMA 36130
ATTENTION:
PART 1 - Taxpayer Identification Number, Name, and Address.
Identification Number ___ ___ ___ ___ ___ ___ ___ ___ ___ (must be nine digits)
Check One ___
Federal Employer Identification Number (FEIN)
___
Social Security Number (SSN) (Print Name as used for Your Federal Income Reporting
on the line and your business name on the second line.)
NAME
ADDRESS
PART 2 - BUSINESS DESIGNATION.
Circle the designation that identifies your type of trade or
business.
1-
CORPORATION OR PROFESSIONAL CORPORATION (A corporation formed under the laws of any state
within the United States)
2-
NOT FOR PROFIT CORPORATION (Section 501(c)(3))
3-
PROFESSIONAL ASSOCIATION
4-
PARTNERSHIP, JOINT VENTURE, ESTATE OR TRUST
5-
SOLE PROPRIETORSHIP OR SELF-EMPLOYED (Identification number must be Social Security
6-
Number)
6-
NONCORPORATION RENTAL AGENCY
7-
GOVERNMENTAL ENTITY (City, County, State or U. S. Government)
8-
FOREIGN CORPORATION OR FOREIGN NATIONAL OR OTHER FOREIGN ENTITY (A corporation or other
foreign entity formed under the laws of a country other than the United States or an
individual temporarily in the United States who pays taxes as a citizen other than the
United States.)
NOTE: If several state agencies make payments to your business, it is possible that you have
received more than one of these forms.
If you have already mailed this information, please
disregard this request.
Failure to complete and return this form may subject you to backup
withholding in the amount of 31% of future payments pursuant to Section 3406, Internal Revenue
Code.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS REQUEST AND TO THE BEST OF MY
KNOWLEDGE
AND
BELIEF, IT IS TRUE, CORRECT AND COMPLETE.
__________________________________
__________________________
(_______)________________________
SIGNATURE
TITLE
TELEPHONE NUMBER
__________________________________
___________________________
PRINTED NAME
DATE
PLEASE INCLUDE FEDERAL IDENTIFICATION NUMBER ON ALL INVOICES

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