W9 Substitute Form

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Central Texas Council of Governments

W9 Substitute

Housing Assistance Division

2180 North Main St ▪ PO Box 729 ▪ Belton Texas 76513

254-770-2300 ▪ 1-888-488-4911 ▪ (Fax) 254-770-2329

Questions regarding this form should be directed to Edith Cooke at 254/770-2311 or Deana Belk at 254/770-2309

Unit Address:_____________________________________________, City______________________

Please complete the following information. We are required by law to obtain this information from you when making a reportable payment to you, and

because the payment is reportable on a Form 1099 to the IRS. You are required by law to provide your correct Social Security number or Employer

Identification Number to us. If you do not provide us with this information, your payments may be subject to 28% federal income tax backup withholding.

Also, if you do not provide us with this information, you may be subject to a $50.00 penalty imposed by the Internal Revenue Service under section 6723.

Federal law on backup withholding preempts any state or local law remedies, such as any right to a mechanic’s lien. If you do not furnish a valid TIN, or if

you are subject to backup withholding, the payer is required to withhold 28% of its payment to you. Backup withholding is not a failure to pay you. It is an

advance tax payment. You should report all backup withholding as a credit for taxes paid on your federal income.

PRIVACY NOTICE:

1. You are entitled to request to be informed about the information about yourself collected by use of this form (with a few exceptions as

provided by law);

2. You are entitled to receive and review that information; and

3. You are entitled to have the information corrected at no charge to you.

INSTRUCTIONS FOR BELOW:

1. Complete part 1 by completing the one row of boxes that corresponds to your tax status.

2. Complete part 2 if you are exempt from Form 1099 reporting.

3. Complete Part 3 by filling in all lines.

Part 1 – Tax Status

(Complete ONLY ONE ROW of boxes)

A Sole Proprietorship may have a “Doing Business As” (dba) trade name, but the legal name is the individual’s name.

Individuals/

Individual Name: (First name, middle initial, last name)

Tax ID

Sole Proprietor

Employer ID

DBA Name:

Number/ SS

(Fill out this row)►

Number

Partnership’s

Partnership:

Partnership’s Name

Name of

Tax

(or an LLC with

on IRS Records

multiple owners)

Partnership:

Identification

(See IRS Mailing label)

(Fill out this row)►

Number

A corporation may use an abbreviated name or its initials, but its legal name is the name on the Articles of Incorporation.

Corporation or

Name of Corporation

Employer

Tax-Exempt Entity

or Entity:

Identification Number

(Fill out this row) ►

Part 2 – Exemption: If exempt from Form 1099 reporting, check your qualifying exemption reason below:

□

Corporation – Note, there is

Tax Exempt Entity

The United States

A state, the District of

A foreign government or political subdivision

no corporate exemption for

under 501(a) includes

or any of its agencies

Columbia, a possession of the

or international organization in the United

payments for medical,

501c(3) or IRA.

or instrumentalities.

United States, or any of their

States participating under a treaty or act of

healthcare or legal services.

political subdivisions or agencies.

congress.

Under penalty 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 me 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 or

dividends, or

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)

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

have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.

Part 3 - Certification

Name:

Title:

Signature:

Phone:

Correspondence ATTN to:

Check To:

Address:

City:

State:

Zip: