Fax Cover Sheet - Upmc Health Plan, Form W-9 - Request For Taxpayer Identification Number And Certification - Department Of Treasury Page 2
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5W-9
Request for Taxpayer
Give form to the
Form
requester. Do not
(Rev. November 2005)
Identification Number and Certification
send to the IRS.
Department of the Treasury
Internal Revenue Service
Name (as shown on your income tax return)
Business name, if different from above
Individual/
Exempt from backup
Partnership
Corporation
Other
Check appropriate box:
Sole proprietor
withholding
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Taxpayer Identification Number (TIN)
Part I
Social security number
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
–
–
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
or
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Employer identification number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
–
Part II
Certification
Under penalties 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 be 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 Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) 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 backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)
Sign
Signature of
Here
U.S. person
Date
● An individual who is a citizen or resident of the United
Purpose of Form
States,
A person who is required to file an information return with the
● A partnership, corporation, company, or association
IRS, must obtain your correct taxpayer identification number
created or organized in the United States or under the laws
(TIN) to report, for example, income paid to you, real estate
of the United States, or
transactions, mortgage interest you paid, acquisition or
● Any estate (other than a foreign estate) or trust. See
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Regulations sections 301.7701-6(a) and 7(a) for additional
information.
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
Special rules for partnerships. Partnerships that conduct a
person requesting it (the requester) and, when applicable, to:
trade or business in the United States are generally required
to pay a withholding tax on any foreign partners’ share of
1. Certify that the TIN you are giving is correct (or you are
income from such business. Further, in certain cases where a
waiting for a number to be issued),
Form W-9 has not been received, a partnership is required to
2. Certify that you are not subject to backup withholding, or
presume that a partner is a foreign person, and pay the
3. Claim exemption from backup withholding if you are a
withholding tax. Therefore, if you are a U.S. person that is a
U.S. exempt payee.
partner in a partnership conducting a trade or business in the
In 3 above, if applicable, you are also certifying that as a
United States, provide Form W-9 to the partnership to
U.S. person, your allocable share of any partnership income
establish your U.S. status and avoid withholding on your
from a U.S. trade or business is not subject to the
share of partnership income.
withholding tax on foreign partners’ share of effectively
The person who gives Form W-9 to the partnership for
connected income.
purposes of establishing its U.S. status and avoiding
Note. If a requester gives you a form other than Form W-9 to
withholding on its allocable share of net income from the
request your TIN, you must use the requester’s form if it is
partnership conducting a trade or business in the United
substantially similar to this Form W-9.
States is in the following cases:
For federal tax purposes, you are considered a person if you
● The U.S. owner of a disregarded entity and not the entity,
are:
W-9
Cat. No. 10231X
Form
(Rev. 11-2005)
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