Form Wolfs-109 - Request For Taxpayer Identification Number & Certification

Download a blank fillable Form Wolfs-109 - Request For Taxpayer Identification Number & Certification in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Wolfs-109 - Request For Taxpayer Identification Number & Certification with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

* click here to clear form data *
Wyoming Department of Transportation
WYOMING DEPT. OF TRANSPORTATION
5300 BISHOP BLVD.
CHEYENNE, WY 82009
(307) 777-4029
REQUEST FOR TAXPAYER
FAX (307) 777-3858
IDENTIFICATION NUMBER & CERTIFICATION
PLEASE PRINT O R TYPE :
Forms that are illegible or incomplete will not be processed.
See Instructions on Page 2
PURPOSE OF THE FORM :
The State of Wyoming is required to file an information return with the IRS, so a correct Taxpayer Identification Number (TIN) is required below.
IRS regulations provide the following: If you fail to furnish your correct TIN to a requestor, you may be subject to a penalty of $50 for each such failure unless your failure is due
to reasonable cause and not to willful neglect. If you make a false statement with no reasonable basis that results in no backup withholding, you may be subject to a $500 penalty.
If you willfully falsify certifications or affirmations you may be subject to criminal penalties including fines and/or imprisonment.
A. OWNERSHIP TYPE THAT APPLIES TO YOU OR YOUR BUSINESS: (you must check only one owner ship type below, and supply the applicable SSN or EIN )
Individual
SSN: _____________________________________
Sole Proprietor (includes one-member Limited Liability Companies) SSN: ________________________________ OR EIN: ________________________________
Partnership (includes Limited Liability Companies with two or more members)
Corporation (Prof. Corp., S-Corp, etc.)
Governmental Entity
Nonprofit Corp.
Trust
Other (be specific) _________________________
EIN: _____________________________________
B. ADDITIONAL INFORMATION: (required)
OFFICIAL TAX REPORTING NAME: ___________________________________________________________________________________________________________
BUSINESS, TRADE OR “DBA” NAME (if different from above): _____________________________________________________________________________________
MAILING ADDRESS (Number, Street, and Apt. or PO Box): _________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
City
State
Zip Code
PHONE NUMBER (include area code): ___________________________________ E-MAIL: ______________________________________________________________
BUSINESS DESCRIPTION: ___________________________________________________________________________________________________________________
C. ELECTRONIC FUNDS TRANSFER PREFERENCE (check one):
I DO NOT desire payment by Electronic Funds Transfer (EFT). Sign certification below.
I DO desire payment by Electronic Funds Transfer (EFT). Check one of the options below, then sign certification below.
NOTE: The State reserves the right to debit or reverse a credit made erroneously to an account without prior notification.
OPTION ONE: Attach a photocopy of a "voided check" or an actual voided check (Do not attach a "deposit slip", since
deposit slips do not contain sufficient information for processing). STOP HERE, NO FURTHER ACTION IS REQUIRED.
OR
OPTION TWO: Have a representative from your financial institution complete all of the following required information.
ABA ROUTING NUMBER: __________________________________________________________________________________________________
FINANCIAL INSTITUTION NAME: ___________________________________________________________________________________________
ACCOUNT NUMBER: ______________________________________________________________________________________________________
FINANCIAL INSTITUTION STREET OR P.O. BOX ADDRESS: _____________________________________________________________________
FINANCIAL INSTITUTION CITY, STATE, ZIP: __________________________________________________________________________________
ACCOUNT TYPE: (check one)
C-CHECKING
S-SAVINGS
SIGNATURE OF FINANCIAL INSTITUTION REPRESENTATIVE: __________________________________________________________________
I CERTIFY UNDER PENALTY OF PERJURY THAT:
1. 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
*2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding
as a result of a failure to report all interest and dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
* You must cross out item number “2" above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest
and dividends on your tax return.
SIGNATURE: _______________________________________________________________
DATE: ____________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2