Form Nj W-9 - Questionnaire With Instructions - State Of New Jersey (Page 2 of 2) in pdf

STATE OF NEW JERSEY

W-9/QUESTIONNAIRE

THE STATE OF NEW JERSEY REQUIRES THE FOLLOWING INFORMATION TO ESTABLISH YOUR NAME, ADDRESS AND TAXPAYER ID ON STATE RECORDS. THE

INFORMATION IS USED TO POPULATE AND MAINTAIN THE STATE’S VENDOR/PAYEE FILE AND MUST BE COMPLETED BEFORE PAYMENTS ARE MADE.

IMPORTANT: YOU WILL NOT BE PAID BY THE STATE OF NEW JERSEY UNTIL THIS FORM IS COMPLETED, SIGNED AND

Return completed form to:

OMB VENDOR CONTROL

RETURNED. FOR ADDITIONAL INFORMATION CALL (609) 633-8183 OR EMAIL: AAIUNIT@TREAS.NJ.GOV

PO BOX 221

TRENTON, NJ 08625 or

PART I.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

FAX: (609) 984-5210

Name (as shown on your tax return):

Doing business as (if different than name):

Address line 1:

Address line 2:

City:

State:

Zip:

If the above contains preprinted data that is incorrect, cross it out and write the correct information immediately next to it.

Taxpayer Identification Number (TIN) Enter your TIN below and select the type of number listed.

SOCIAL SECURITY NUMBER

EMPLOYER IDENTIFICATION NUMBER

5. Certification: Under penalties of perjury, I certify 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 Internal Revenue Service (IRS)

that I am subject to backup 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, and

(3) I am a U.S. citizen or other US person as defined by the IRS.

Certification Instructions: You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of

underreported interest or dividends on your tax return. For real estate transactions, item (2) does not apply. For mortgage interest paid, acquisition or

abandonment of secured property, cancellation of debt, contributions to an IRA, and generally payments other than interest or dividends, you are not required to

sign the certification, but you must provide your correct TIN.

Sign

Signature

Date

Here

PART II.

VENDOR/PAYEE DATA: STATE OF NEW JERSEY VENDOR/PAYEE INFORMATION QUESTIONNAIRE

Enter the code from the list below that best describes your primary business function:

VENDORS

VG=VENDORS WHO SELL OR MANUFACTURE GOODS

HC=HEALTHCARE SERVICES (NON STATE AGENCIES)

VS=VENDORS WHO RENDER SERVICE OR RECEIVE RENT PAYMENTS

LG=LEGAL SERVICES

CS=CONSTRUCTION VENDORS WHO RENDER SERVICES

CG=CONSTRUCTION VENDORS WHO SELL OR MANUFACTURE GOODS

GOVERNMENT ENTITIES

AC=AUTHORITY/COMMISSION

CF=CONFIDENTIAL FUND

PC=PETTY CASH

SD=SCHOOL DISTRICT

FA=FEDERAL AGENCY

FD=FIRE DISTRICT

CM=COUNTY/MUNICIPALITY

EP=NJ STATE EMPLOYEE

SA=STATE AGENCY

WB=WELFARE BOARD

CU=STATE COLLEGE/UNIVERSITY

OTHER VENDORS

OT=OTHER VENDOR (PLEASE SPECIFY)_____________________

Primary Contact Information

(ALL FIELDS ARE REQUIRED):

Name: _____________________________Phone:______________________ Email: _________________________________________

Please check here if you are interested in receiving information about payments by direct deposit.

IF YOU ARE A NJ STATE EMPLOYEE, NJ MANAGER OF A CONFIDENTIAL FUND OR PETTY CASH FUND, DO NOT ANSWER THE BALANCE OF THE QUESTIONAIRE.

What is the principle activity of your organization?

M=MANUFACTURING

H=HEALTH RELATED SERVICE

C=CONSTRUCTION

L=LEGAL

S=SERVICE

G=GOVERNMENT

O=OTHER (PLEASE SPECIFY)___________________

Enter the code from the list below that best describes your organization

C=CORPORATION

I=INDIVIDUAL

P=PARTNERSHIP L= LIMITED LIABILITY COMPANY

IMPORTANT: ANSWER ALL QUESTIONS (PRINT CLEARLY OR TYPE)

Form NJ W-9 (Rev 6/2014)

Form Nj W-9 - Questionnaire With Instructions - State Of New Jersey Page 2

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