Vendor Addition/change Form - Steuben County
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1
2FINANCE OFFICE –
–
STEUBEN COUNTY
Vendor Addition/Change Form
3 EAST PULTENEY SQUARE, Room 301 – BATH, NEW YORK 14810
PHONE: Vendor Questions: (607) 664-2488
FAX: (607) 664-2188
The information below, that we are requesting, is required for us to process any payments to you.
15 days
Please return this form within
to AVOID DELAY IN PAYMENT or BACKUP WITHHOLDING.
W-9 –TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION - PLEASE TYPE OR PRINT CLEARLY
Name (as shown on your income tax return)___________________________________________________
Business Name (if different from above)______________________________________________________
Check appropriate box:
____Individual/Sole Proprietor
____Corporation
____Partnership
OR LLC
Individual/Sole Proprietor
____Corporation
____Partnership
(Limited Liability Company):
_____
Taxpayer Identification Number (TIN):
Enter your TIN in the appropriate box. The TIN provided must match the name
given to avoid backup withholding. For individuals, this is your social security number. For other entities this is your employer
identification number. See W-9 instructions for more information.
Social Security Number _ _ _ - _ _ - _ _ _ _
Employer Identification Number _ _ - _ _ _ _ _ _ _
Certification:
Under penalties of perjury, I certify that: 1) I am not subject to backup withholding; 2) The number shown on this form is my correct
Federal Identification Number; 3) The information I have supplied is correct; and 4).that I am a US citizen.
Signature ______________________________________
Date ____________
WARNING: PURSUANT TO SECTION 175.35 OF THE PENAL LAW, A PERSON WHO INTENDS TO DEFRAUD THE STATE OR ANY POLITICAL
SUBDIVISION THEREOF BY OFFERING OR PRESENTING A WRITTEN INSTRUMENT WHICH HE OR SHE KNOWS CONTAINS A FALSE STATEMENT
OR FALSE INFORMATION TO PUBLIC OFFICE WILL BE FILED WITH, REGISTERED OR RECORDED IN OR OTHERWISE BECOME A PART OF THE
RECORDS OF SUCH PUBLIC OFFICE OR PUBLIC SERVANT, IS GUILTY OR OF CLASS “E” FELONY CARRYING A POSSIBLE SENTENCE OF 4 YEARS
IN PRISON, A $5,000 FINE, OR BOTH.
---------------------------------------------------------------------------------------------------------------------------------------
PAY TO ADDRESS
PURCHASING ADDRESS
(if different)
Address #1
_______________________________________
_______________________________________
Address #2
_______________________________________
_______________________________________
City, State, Zip _______________________________________
_______________________________________
Contact Person _______________________________________
_______________________________________
Phone Number _______________________________________
_______________________________________
COUNTY USE: Requested by: __________________________ Dept: ________ Extension: ________
N
E
M
R
L
Primary 1099 Code: ________
(No 1099),
(Non-Employee),
(Medical),
(Rent),
(Legal)
NOTES:
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