Form Ao 213 - Vendor Information/tin Certification Page 2
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2AO 213
)
(Rev. 06/ 12
Definitions:
"Taxpayer Identification
" is the number required by the Internal Revenue Service (IRS) to be used in
(TIN, SS, or EIN number)
reporting income tax and other returns. The TIN may be either a social security number (SSN) or an employer identification
number (EIN).
"U.S. person" means:
!
An individual who is a U.S. citizen or U.S. resident alien,
!
A partnership, corporation, company, or association created or organized in the United States or under the laws of
the United States.
The TIN, as well as the information above is required in order to comply with debt collection requirements of
31 U.S.C. §§ 7701(c)
and 3325(d), reporting requirements of
26 U.S.C. §§ 6041
and 6041A, and implementing regulations issued by the IRS. Failure or
refusal to furnish this information may result in 28 percent backup withholding on any payments otherwise due under any awarded
contract or purchase order.
The TIN may be used by the government to collect and report on any delinquent amounts arising out of the vendor's relationship with
the government
(31 U.S.C. §
7701(c)(3)). The TIN provided may be matched with IRS records to verify its accuracy.
Complete this section only if a TIN was not provided on page one, and select closest reason why not:
’
The vendor is a nonresident alien, foreign corporation or foreign partnership that does not have income effectively
connected with the conduct of a trade or business in the United States and does not have an office or place of business
or a fiscal paying agent in the United States;
’
The vendor is an agency or instrumentality of a foreign government;
Additional information required for vendors used for procurement
(purchase orders, contracts, etc.)
Indicate which, if any, of the following categories are applicable. These categories require that the vendor is 51% owned and the
management and daily operations are controlled by one or more members of the selected socio-economic group:
’
’ Not Applicable
Women Owned Business
’
Minority Owned Business
:
(If yes, select one of the owner's race/ethnicity selections from below)
’
’
’
Asian-Pacific American
Black American
Subcontinent Asian (Asian-Indian)American
’
’
’
Hispanic American
Native American
Other:
Date:
Vendor’s signature
For Agency Use Only
The vendor name and DUNS number is all that is required for registered System for Award Management (SAM) vendors (formerly
CCR). (Check
for registration status.) Do not use this form for purchase card merchants.
’
’
’
Mark Boxes that apply:
Addition
Change
Vendor Code:
(make entry only if change)
’
’
’
Active
Inactive
Vendor Type:
The following information is optional for individuals whose name and telephone are already on the form:
Contact Name:
Telephone Number:
Email:
Identification of person making this request:
Name:
Telephone Number:
Originating Office:
Please type or print clearly.
For “AO” FAS4T Users only, e-mail the completed form to:
AOdb_OFB_Client Service
Desk/DCA/AO/USCOURTS. For questions
regarding AOFAS4T the Client Service Desk can be contacted at (202) 502-2242.
For “Court” FAS4T Users, send this form to the local Vendor Administrator. For questions regarding Court FAS4T please contact
SDSD at (210) 301-6320.
This form should be completed with signature by the vendor and submitted by Judiciary staff only.
Sensitive information must be securely maintained and only visible to the appropriately designated financial employee.
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