Substitute Form W-9 - Request For Taxpayer Identification Number printable pdf download

IMPORTANT TAX DOCUMENT

SUBSTITUTE FORM W-9

Request for Taxpayer Identification Number

The Internal Revenue Service Center (IRS) requires that we request your Taxpayer Identification Number (TIN) for information reporting

purposes. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide us with this

information, your payments may be subject to 28% federal income backup withholding. Also, if you do not provide us with this information, you

may be subject to a $50 penalty imposed by the Internal Revenue Service under Section 6723 of the Internal Revenue Code.

1. Taxpayer Name

_________________________________________________________

(To whom the check is payable)

Actual recipient of payment - This MUST BE the legal entity name

registered with IRS if a corporation or partnership; the business owner's

name if a sole proprietor. You must provide this information)

Doing Business as:

(A division name if a corporation or

DBA_________________________________________________

The name of the business if a sole proprietor)

2. Taxpayer Address

______________________________________________________

3. Taxpayer Identification Number (TIN)

a. Corporation

______________________________________________________

(List employer identification number)

b. Partnership

______________________________________________________

(List employer identification number)

c. Individual

______________________________________________________

(List social security number)

d. Sole Proprietorship

______________________________________________________

(List social security number or employer identification number)

e. Tax Exempt Entity

______________________________________________________

(List employer identification number) Please attach a copy of your tax-

exempt status letter from the IRS.

4. Certification

Under penalties of perjury, I certify that:

a. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).

b. I am not subject to backup withholding because: (i) I am exempt from backup withholding, or (ii) I have not been notified by the Internal

Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified me

that I am no longer subject to backup withholding, and

c. I am a U.S. person (including a U.S. resident alien). If you are a foreign person, use the appropriate Form W-8. See Pub.515, Withholding of

Tax on Nonresident Aliens and Foreign Corporations.

______________________________________________________

(Print name)

5. Signature

_________________________________________________________

(Signature)

6. Today’s Date

______________________________________________________

7. Daytime Phone Number

______________________________________________________

PLEASE NOTE: INFORMATION REPORTED ON LINES 1-3 MUST BE CONSISTENT WITH DATA REGISTERED WITH

THE IRS AND SOCIAL SECURITY ADMINISTRATION.

Please return this completed form to:

Medica Agent Services

P. O. Box 9310, Mail Route CW290

Minneapolis, MN 55440-9310

Substitute Form W-9 - Request For Taxpayer Identification Number

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