State Of South Dakota Substitute W-9 - Taxpayer Identification Number (Tin) Verification - Northern State University


State of South Dakota
Northern State University
Purchasing or Finance Office
1200 South Jay St
Aberdeen SD 57401
Fax: 605-626-3022
DO NOT send to IRS
Taxpayer Identification Number (TIN) Verification
Type (preferred) or Print
Please see attachment or reverse for complete instructions.
Legal Name
Entity Designation
(check only one)
(as entered with IRS) If Sole Proprietorship enter your Last, First MI
Individual / Sole Proprietor
Corporation (includes service corporations)
Trade Name
Limited Liability Company - Partnership
If doing business as (DBA) or enter business name of Sole Proprietorship
Limited Liability Company - Corporation
Government Entity
Order Address
(where orders should be mailed)
Hospital Exempt from Tax or Government
PO Box or Number and Street, City, State, ZIP + 4
Long Term Care Facility Exempt from Tax or
Government Owned
All Other Entities
Taxpayer Identification Number (TIN)
Remit Address
(where checks should be mailed, if different from Order
If you are a sole proprietor and you have an EIN,
PO Box or number and street, City, State, ZIP + 4
you may enter either your SSN or EIN. However,
using your EIN may result in unnecessary notices
to the requester.
__ __ __ __ __ __ __ __ __
Business Classification – T
his section is voluntary and
Check Only One
information provided is confidential. Check all that are applicable
Social Security Number (SSN)
Employer Identification Number (EIN)
Small Business
Disadvantage Business
Individual Taxpayer Identification Number
HUBZone Small Business
Minority Institution
for U.S. Resident Aliens (ITIN)
Veteran Owned Small Bus.
Minority-Owned Business
Service Disabled Veteran Owned Small Business
Woman Owned Business
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, AND
I am not subject to back up 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 back up 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.
3. I am a U.S. person (including a US resident alien).
Printed Name
Printed Title
Telephone Number
/ Facsimile Number (Required)
Optional Direct Deposit Information ***
Your Bank Account Number
Type of Account
Bank Name
Bank Routing No. (9-digit ABA #)
new direct deposit
change of existing
additional direct deposit
email change only
Order From E-mail address
(Please make this LEGIBLE)
Remit To E-mail address
(If different from Order From)
***If you provide your Direct Deposit information you must also provide an accurate email address.


00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Page of 3