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INSTRUCTIONS

WHY YOU RECEIVED THIS FORM: A State of Oregon agency has established an account for the named person or business. Payments may

be made for services, supplies, or as a reimbursement. All information supplied is confidential and will be for the purpose of reporting to IRS

those payments already subject to such reporting requirements or may be disclosed to federal law enforcement and intelligence agencies to

combat terrorism.

NAME & ADDRESS: Verify that the name and address on the form are correct. If not correct, draw a line through the incorrect

information and write the correct information to the side. The name must be written on the form exactly as it appeared on Form SS-4,

Application for Employer Identification Number. Enter your telephone and fax numbers, if incorrect or missing.

BUSINESS NAME: Enter any business, trade, or “doing business as (DBA)” name. The ORGANIZATION TYPE and NAME must be for

the same entity.

FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): Verify that the FEIN is correct for the entity named on the form. If the

FEIN preprinted on the form is incorrect, draw a line through it and write in the correct number.

ORGANIZATION TYPE: The following definitions and type of number required may help identify the correct selection:

Sole Proprietor -

Any business or venture owned by a single person. Give name of the owner.

Partnership, LLC, LLP, TRUST -

Any business or venture owned by two or more partners.

Corporation, Not Medical or Attorney -Any corporation formed under the laws of any U.S. state or territory except for not for profit,

governmental, medical/health care or attorneys.

Medical/Health Care -

Any business or venture that provides medical or health care services, either incorporated or not

incorporated.

Attorney-At-Law -

Attorney-at-Law, either incorporated or non-incorporated.

Not for Profit -

Any non-profit organization formed under the laws of any U.S. state or territory. A copy of your

EXEMPTION LETTER from the IRS is required.

Government Agency -

Any part of the government of the United States or of any state.

Local Government -

Any local government agency or political subdivision of the State of Oregon.

Certification: IRS requires an individual or organization that is subject to backup withholding to have withholdings at a rate set by the IRS,

from any 1099-MISC reportable payment. The amount deducted is paid directly to IRS. Backup withholding is NOT a monthly or quarterly

payroll tax withholding. You are subject to backup withholding if: 1) you have received a special notice telling you so, or 2) you failed to

provide a correct Taxpayer ID Number (TIN) as requested, or 3) you failed to report interest or dividend income. Sign the form to certify under

penalties of perjury all items listed in box 5. Return the form to the address below.

PENALTIES-

Failure to Furnish TIN - If you fail to furnish your correct TIN to a requestor, you are subject to a penalty of $100 for each such failure unless

your failure is due to reasonable cause and not willful neglect.

Civil Penalty for False Information With Respect to Withholding – If you make a false statement with no reasonable basis that results in no

backup withholding, you are subject to a $500 penalty.

Criminal Penalty for Falsifying Information – Willfully falsifying certifications or affirmations may subject you to criminal penalties

including fines and/or imprisonment.

Misuse of TINs – If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

SIGNATURE: Sign the form to certify that the information on the form is valid. Print or type your name below the signature.

Return this form by mail to:

Oregon Department of Administrative Services

Enterprise Goods & Svcs/Financial Business Sys

Statewide Financial Management Services

155 Cottage St. NE

Salem, OR 97301-3963

This form may be faxed to: (503) 378-8940

AFTER READING THE INSTRUCTIONS you may contact SFMS at (503) 373-0256 for additional information. Thank you for your

cooperation.

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To sign up for direct deposit payment service and receive convenient, electronic payments, open the following website to access a

Direct Deposit Authorization form. Select the vendor form in .pdf or .docx format.

REVISED 5/2/2016

Form W-9 (Substitute) - Request For Taxpayer Identification And Certification - Oregon Department Of Administrative Services Page 2

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