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State Of South Dakota Substitute W-9 - Taxpayer Identification Number (Tin) Verification - Northern State University Page 3

Taxpayer Identification Request

In order for the State of South Dakota to comply with the Internal Revenue Service regulations, this letter

requests that you complete the enclosed Substitute Form W-9. Failure to provide this information may

result in delayed payments or backup withholding. This request is being made at the direction of the

South Dakota Bureau of Finance and Management in order that the State may update its vendor file with

the most current information.

Please return or FAX the Substitute Form W-9 even if you are exempt from backup withholding within (10)

days of receipt. Please make sure that the form is complete and correct. Failure to respond in a timely

manner may subject you to a 28% withholding on each payment or require the State to withhold

payment of outstanding invoices until this information is received.

We are required to inform you that failure to provide the correct Taxpayer Identification Number (TIN) /

Name combination may subject you to a $50 penalty assessed by the Internal Revenue Service under

section 6723 of the Internal Revenue Code.

Only the individual’s name to which the Social Security Number was assigned should be entered on the

first line.

The name of a partnership, corporation, club, or other entity, must be entered on the first line exactly as it

was registered with the IRS when the Employer Identification Number was assigned.

DO NOT submit your name with a Tax Identification Number that was not assigned to your name. For

example, a doctor MUST NOT submit his or her name with the Tax Identification Number of a clinic he or

she is associated with.

Please complete the Fax information so Purchase Orders can be sent to you electronically if applicable.

Please complete the Direct Deposit Information if you wish to have your payments direct deposited.

Also, please provide an accurate email address so the deposit information can be sent to your remit to

email address.

Thank you for your cooperation in providing us with this information. Please return the completed form to:

Northern State University

Purchasing Office

1200 S Jay St

Aberdeen SD 57401

Or send faxes to:

605-626-3022

Enclosure

State Of South Dakota Substitute W-9 - Taxpayer Identification Number (Tin) Verification - Northern State University Page 3