Existing Vendor Change Of Business Form, Form W-9 - Request For Taxpayer Identification Number And Certification Page 2

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LOS ANGELES UNIFIED SCHOOL DISTRICT, PROCUREMENT

EXISTING VENDOR CHANGE OF BUSINESS FORM

Phone: (562) 654-9404; Fax: (562) 654-9498; E-mail:

psg-vsu@lausd.net

CHANGE TYPE (select all that apply):

Address

Business Name

Taxpayer Identification Number (TIN)

Other ____________

For changes to Vendor/Business Name and Taxpayer Identification Number, please provide supporting documentation. Examples: proof of

acquisition by another company/vendor, or a notice from the IRS Department of the Treasury stating that a TIN has been assigned or certifying a

TIN is assigned to a company at a particular address.

VENDOR INFORMATION AS CURRENTLY SHOWN IN LAUSD’s FINANCIAL SYSTEM:

LAUSD VENDOR NO.:

VENDOR NAME:

TAXPAYER IDENTIFICATION NUMBER (TIN):

Employer Identification Number (FEIN)

Social Security Number (SSN)

EIN:

SSN:

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHONE:

FAX:

CONTACT NAME:

UPDATE VENDOR INFORMATION IN LAUSD’s FINANCIAL SYSTEM TO THE FOLLOWING:

VENDOR NAME:

DOING BUSINESS AS (DBA), if applicable:

TAXPAYER IDENTIFICATION NUMBER (TIN):

1099 Reportable?

Yes

Employer Identification Number (EIN)

Social Security Number (SSN)

EIN:

SSN:

STATE OF CALIFORNIA SELLER’S PERMIT NUMBER / USE TAX ACCOUNT / RESALE NUMBER:

This number is issued by the California State Board of Equalization with a numbering format similar to ABC XYZ 12-3456789

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHONE:

FAX:

CONTACT NAME:

E-MAIL

SMALL BUSINESS ENTERPRISE (SBE):

Is your organization a certified SBE?

Yes

Certifying Agency:

If your organization is a Small Business Enterprise (SBE), please provide proof of certification from any California public agency. See Instructions page.

I certify under penalty of perjury the information supplied herein is true and correct.

Vendor Signature:

Date:

Print Name and Title of Vendor Representative signing form:

FAX COMPLETED FORM AND ANY SUPPORT DOCUMENTATION ALONG WITH IRS FORM W-9 (Request for Taxpayer Identification

Number and Certification) TO PROCUREMENT’S PREQUALIFICATION / VENDOR SERVICES UNIT AT

(562) 654-9498

LAUSD Existing Vendor Change of Business Form

Rev. 1/2012