Form Ac 3237 (Substitute Form W-9) - Request For Taxpayer Identification Number & Certification - New York State Office Of The State Comptroller - 2009

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AC 3237 (12/09)
NEW YORK STATE OFFICE OF THE STATE COMPTROLLER
SUBSTITUTE FORM W-9:
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER & CERTIFICATION
TYPE OR PRINT INFORMATION NEATLY. PLEASE REFER TO INSTRUCTIONS FOR MORE INFORMATION.
Part I: Vendor Information
1. Legal Business Name:
2. If you use a DBA, please list below:
3. Entity Type (Check one only):
Sole Proprietor
Partnership
Limited Liability Co.
Business Corporation
Unincorporated Association/Business
Federal Government
State Government
Public Authority
Local Government
School District
Fire District
Other _______________________________
Part II: Taxpayer Identification Number (TIN) & Taxpayer Identification Type
1. Enter your TIN here: (DO NOT USE DASHES)
2. Taxpayer Identification Type (check appropriate box):
Employer ID No. (EIN)
Social Security No. (SSN)
Individual Taxpayer ID No. (ITIN)
N/A (Non-United States Business Entity)
Part III: Address
1. Physical Address:
2. Remittance Address:
Number, Street, and Apartment or Suite Number
Number, Street, and Apartment or Suite Number
City, State, and Nine Digit Zip Code or Country
City, State, and Nine Digit Zip Code or Country
Part IV: Exemption from Backup Withholding and Certification
For payees exempt from Backup Withholding, check the box below. Valid explanation required for exemption. See instructions.
Exempt from Backup Withholding
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding. Under penalties of perjury, I certify that the number shown on this form is my correct Taxpayer Identification Number (TIN).
Sign Here:
___________________________________________________________
___________________
Signature
Date
___________________________________________________________
______________________
________________________
Print Preparer's Name
Phone Number
Email Address
Part V: Contact Information – Individual Authorized to Represent the Vendor
Vendor Contact Person: ___________________________________________
Title:_____________________________________________
________________________
Contact’s Email Address: ______________________________________________________
Phone Number:
DO NOT SUBMIT FORM TO IRS - SUBMIT FORM TO NYS ONLY AS DIRECTED
By FAX (518) 473-4392, Email
VMU@osc.state.ny.us
or mail to:
110 State Street Mail Drop 10-4 Albany, NY 12236-0001
FOR OSC USE ONLY

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