REQUEST FOR TAXPAYER IDENTIFICATION AND CERTIFICATION
YOU RECEIVED THIS FORM because a state agency may make a payment to you for services, supplies, or as a reimbursement.
YOU ARE REQUIRED BY IRS to provide complete and accurate tax identification information
READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM.
Accurately completing this form will assist us in establishing your account for payment processing.
NAME & ADDRESS
State Use Only
2. BUSINESS NAME
4. ORGANIZATION TYPE
You Must Check One Only. Make sure that the
V I O
organization type corresponds to the tax identification
number in box 3.
5 Y T
____ Sole Proprietor, Partnership, LLC, LLP, Trust
5 N O
____ Corporation, not Medical or Attorney
5 Y N
____ Medical Health Care, Incorporated or not
You may enter your business, trade, or “doing
business as (DBA)” name on the Business
5 Y P
5 N G
____ Not for Profit (copy of Exemption Letter from
the IRS is required)
3 N G
____ State/Federal Government Agency
4 N G
____ Local Government/Political Subdivision
3. FEDERAL EMPLOYER IDENTIFICATION
Under penalties of perjury, I certify that:
To sign up for direct
deposit payment service
You must provide your FEIN whether or not you are required to
1. The number shown on this form is my correct taxpayer
file a tax return.
and receive convenient,
identification number (or I am waiting for a number to be issued
to me); and
open the following
website to access a
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
Select the vendor form
interest or dividends, or (c) the IRS has notified me that I am no
in .pdf or .docx format.
longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person.
Payers must generally withhold at the current IRS backup
withholding rate for taxable interest, dividend, and certain other
Certification instructions. You must cross out item 2 above if
payments to a payee who does not give a TIN to a payer. See
you have been notified by the IRS that you are currently subject
back of form for applicable penalties and instructions.
to backup withholding because you have failed to report all
interest and dividends on your tax return. For payments other
than interest and dividends, you are not required to sign the
certification, but you must provide your correct TIN.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid
AUTHORIZED SIGNATURE ________________________________________________________________________________
NAME (print or type) _______________________________________________________________________________________
(If representing a business/organization)