Student School And Activity Fund Application - Union Public Schools, Form W-9 - Request For Taxpayer Identification Number And Certification Page 2

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For Office Use Only
Choctaw Nation of Oklahoma
Date Received
Student School and Activity Fund
TM
SS
W9
BLACK OR BLUE INK ONLY!
Absolute Application Deadline is August 1, 2012
Incomplete applications are logged in and discarded!
PLEASE PRINT CLEARLY AND COMPLETE ALL 10 LINES OF THIS SECTION
Student Name:_________________________________________________Date:______________________
Mailing Address:_________________________________________________________________________
City:__________________________________State:________________ZipCode:_____________________
Daytime Phone:____________________Student’s Social Security Number:_________________________
Current School____________________________________________Grade:_________________________
*
*
NO PARENT SIGNATURES
CERTIFICATION FOR SCHOOL CLOTHING OR SCHOOL SUPPLIES
I certify the above student’s school enrollment and grade.
_________________________________________________________________________________
Signature of School Official, Title and Date
CERTIFICATION FOR SPORTS OR ACTIVITIES, SCHOOL OR NON-SCHOOL RELATED
I certify the above student’s enrollment and participation in
Sport/Activity:_________________________________________________
__________________________________________________________________________________
Signature of Coach, Sponsor or Organization Official, Title and Date
COMPLETE SECTIONS 1 AND 2 OR SECTIONS 1 AND 3. Allow a minimum of 8 weeks to receive funds.
•
SEND A COPY OF THE STUDENT’S CHOCTAW MEMBERSHIP CARD, SOCIAL SECURITY CARD,
•
AND A W9 FORM WITH THE STUDENT’S INFORMATION.
Mail to:
Approved for Payment
Student School and Activity Fund
Choctaw Nation of Oklahoma
POB 1210
Durant, OK 74702
____________________________

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