Substitute W-9 Form - Request For Taxpayer Identification And Certification

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SUBSTITUTE W-9 FORM
REQUEST FOR TAXPAYER IDENTIFICATION AND CERTIFICATION
COMPLETE PART 1 OR PART 2 OR PART 3
____________________________________________________________________________________________________________________
#1.
Individual or Sole Proprietor
(Persons known to file as self-employed are required to pay self-employment taxes and file using their Social Security number and are not eligible for unemployment benefits)
___________________________________________________
_____ _____ _____ - _____ _____ - _____ _____ _____ _____
Business Owner’s full legal name (First, MI, Last)
Social Security Number
__________________________________________________________
_______________________________
Business or Trade Name (Doing business as)
Birth Date
____________________________________________________________________________________________________________________
#2.
Business, Partnership, Trust or Joint Venture
_______________________________________
_____ _____ - _____ _____ _____ _____ _____ _____ _____
Name of Business
Business EIN
#3.
Corporations (*Exempt) *
While corporations are exempt (except Attorneys/Law Firms) we still require a W-9 for our files.
___________________________________________________________
_____ _____ - _____ _____ _____ _____ _____ _____ _____
Name of Corporation
Corporation EIN
Date of Incorporation______________________________
Attorney or Law Firm?
Yes____ No____
#4.
Tax Filing Address & Signature
________________________________________
Phone:____(______)__________________
Street
____________________________________________________________
City
State
Zip
Under penalties of perjury, I hereby certify that: 1) the above information is true and correct, 2) I am not subject to
backup withholding, and 3) I am a U.S. person (including a U.S. resident alien).
Signature: __________________________________________ Date: _________________________

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