Form W-9 - Provider Tax Identification Reporting Form

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WV DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Provider Tax Identification Reporting Form
Organization/Individual Name:
____________________________________________________________
Federal Employer Identification Number (FEIN) or Social Security Number: _______________________
Business Address: _______________________________________________________________________
Payment Address: ________________________________________________________________________
Telephone Number (
) ___________________
Contact person: _________________________________
_________________________________________________________________________________________
[_] I wish to withdraw because:
________________________________________________________________________________
[
] I wish to continue providing services (If you mark this box, you must complete the remainder of the form)
________________________________________________________________________________
Pursuant to Internal Revenue Service regulations, Providers must furnish their taxpayer identification number (TIN) to the State. If this number
.
is not provided, you may be subject to a 20% withholding on each payment
_______________________________________________________________________________
ENTER YOUR NAME AND ADDRESS EXACTLY AS YOU ENTER THEM ON YOUR IRS INCOME TAX FORMS
1099/Tax Name: ____________________________________________________________________________________
:
_______________________________________________________________________
1099/Tax Address
):
or
: _______________
Social Security Number
Federal Employer Identification Number (FEIN
__________________________________________________________________________________________
List the Type of Service you are Approved/Licensed to provide:
TYPE
COUNTY (IF APPLICABLE)
___________________________________________________
_________________________________________________
___________________________________________________
_________________________________________________
__________________________________________________________________________________________
Type of Business of Provider ( Check One)
[_] Individual
[_] Sole Proprietorship
[_] Partnership
[_] Government/Non Profit [_] Corporation [_] Public Services Corporation [_] Estate Trust
Other Tax Account Number(s) (if applicable):
State Sales Tax/Use Tax Number: ____________________________________
State Unemployment Tax Number:
State Corporation Income Tax Number: ____________________________
State Employers Withholding Tax Number: ________________________________________________________________________
__________________________________________________________________________________________
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.
Name (Print):
Signature:
_____________________________________________
Date:
____Telephone: (
)
______
Title:
_________________________________________________
Return to:
WVDHHR
W-9
Bureau for Children & Families

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