Form Bfm-0001 - Substitute W-9 Taxpayer Identification Number (Tin) Verification - 2013

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State of South Dakota
Vendor Coordinator
Department of Executive Management
Environment & Natural Resources
BFM-0001 (09/2013)
523 E Capitol Ave
Pierre SD 57501
Send faxes to: 605-773-4068
DO NOT send to IRS
Taxpayer Identification Number (TIN) Verification
Print or Type
Please see pages 2 and 3 for instructions.
Legal Name
(as shown on your income tax return)
Entity Designation
(check only one)
Individual / Sole Proprietor
C Corporation
Business Name, if different from above
S Corporation
(use if doing business as DBA, or enter business name of Sole Proprietorship)
Limited Liability Company – Individual
Limited Liability Company – Partnership
Order-From Address
Limited Liability Company – Corporation
(where orders should be mailed)
PO Box or Number and Street, City, State, ZIP + 4
Governmental Entity
Hospital Exempt from Tax or Government
Long-Term Care Facility Exempt from Tax
or Government Owned
Other Entity (specify, e.g., 501(c)(3), etc):
Remit-To Address
(where payments should be mailed, if different from
PO Box or number and street, City, State, ZIP + 4
Order address)
Taxpayer Identification Number (TIN)
If you are a sole proprietor and you have an EIN,
you may enter either your SSN or EIN. However,
using your EIN may result in unnecessary notices
to the requester.
___ ___ ___ ___ ___ ___ ___ ___ ___
Check Only One
(see instructions, page 3)
Social Security Number (SSN)
Exempt payee code (if any)
Employer Identification Number (EIN)
Exemption from FATCA reporting code (if any)
Individual Taxpayer Identification Number
for U.S. Resident Aliens (ITIN)
(see instructions on page 2)
Under penalties of perjury, I certify that:
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), AND
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report
all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, AND
3. I am a U.S. citizen or other U.S. person, AND
4. The FATCA code(s) entered on this form (if any) indicating I am exempt from FATCA reporting is correct.
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
Printed Name
Printed Title
Telephone Number
Signature of
U.S. Person
Required Direct Deposit Information (all fields required to receive electronic payments)
Your Bank Account Number
Name on Bank Account
Bank Routing No. (9-digit ABA #)
new direct deposit
change of existing
additional direct deposit
email change only
E-mail address (Please make this LEGIBLE)
If you provide bank information and an email address, we will send a message notifying you when an electronic payment is issued. You will
also receive a PIN for use when logging into the SD Vendor Self Service website at We will NOT share your email
address with anyone or use it for any other purpose than communicating information about your electronic payments to you.


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