Fax Cover Sheet - Upmc Health Plan, Form W-9 - Request For Taxpayer Identification Number And Certification - Department Of Treasury Page 3
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52
Form W-9 (Rev. 11-2005)
Page
● The U.S. grantor or other owner of a grantor trust and not
3. The IRS tells the requester that you furnished an
incorrect TIN,
the trust, and
● The U.S. trust (other than a grantor trust) and not the
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
beneficiaries of the trust.
dividends on your tax return (for reportable interest and
Foreign person. If you are a foreign person, do not use
dividends only), or
Form W-9. Instead, use the appropriate Form W-8 (see
5. You do not certify to the requester that you are not
Publication 515, Withholding of Tax on Nonresident Aliens
subject to backup withholding under 4 above (for reportable
and Foreign Entities).
interest and dividend accounts opened after 1983 only).
Nonresident alien who becomes a resident alien.
Certain payees and payments are exempt from backup
Generally, only a nonresident alien individual may use the
withholding. See the instructions below and the separate
terms of a tax treaty to reduce or eliminate U.S. tax on
Instructions for the Requester of Form W-9.
certain types of income. However, most tax treaties contain a
provision known as a “saving clause.” Exceptions specified
Also see Special rules regarding partnerships on page 1.
in the saving clause may permit an exemption from tax to
Penalties
continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.
Failure to furnish TIN. If you fail to furnish your correct TIN
If you are a U.S. resident alien who is relying on an
to a requester, you are subject to a penalty of $50 for each
exception contained in the saving clause of a tax treaty to
such failure unless your failure is due to reasonable cause
claim an exemption from U.S. tax on certain types of income,
and not to willful neglect.
you must attach a statement to Form W-9 that specifies the
Civil penalty for false information with respect to
following five items:
withholding. If you make a false statement with no
1. The treaty country. Generally, this must be the same
reasonable basis that results in no backup withholding, you
treaty under which you claimed exemption from tax as a
are subject to a $500 penalty.
nonresident alien.
Criminal penalty for falsifying information. Willfully
2. The treaty article addressing the income.
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil
4. The type and amount of income that qualifies for the
and criminal penalties.
exemption from tax.
5. Sufficient facts to justify the exemption from tax under
Specific Instructions
the terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty
Name
allows an exemption from tax for scholarship income
If you are an individual, you must generally enter the name
received by a Chinese student temporarily present in the
shown on your income tax return. However, if you have
United States. Under U.S. law, this student will become a
changed your last name, for instance, due to marriage
resident alien for tax purposes if his or her stay in the United
without informing the Social Security Administration of the
States exceeds 5 calendar years. However, paragraph 2 of
name change, enter your first name, the last name shown on
the first Protocol to the U.S.-China treaty (dated April 30,
your social security card, and your new last name.
1984) allows the provisions of Article 20 to continue to apply
If the account is in joint names, list first, and then circle,
even after the Chinese student becomes a resident alien of
the name of the person or entity whose number you entered
the United States. A Chinese student who qualifies for this
in Part I of the form.
exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on
Sole proprietor. Enter your individual name as shown on
his or her scholarship or fellowship income would attach to
your income tax return on the “Name” line. You may enter
Form W-9 a statement that includes the information
your business, trade, or “doing business as (DBA)” name on
described above to support that exemption.
the “Business name” line.
If you are a nonresident alien or a foreign entity not subject
Limited liability company (LLC). If you are a single-member
to backup withholding, give the requester the appropriate
LLC (including a foreign LLC with a domestic owner) that is
completed Form W-8.
disregarded as an entity separate from its owner under
Treasury regulations section 301.7701-3, enter the owner’s
What is backup withholding? Persons making certain
name on the “Name” line. Enter the LLC’s name on the
payments to you must under certain conditions withhold and
“Business name” line. Check the appropriate box for your
pay to the IRS 28% of such payments (after December 31,
filing status (sole proprietor, corporation, etc.), then check
2002). This is called “backup withholding.” Payments that
the box for “Other” and enter “LLC” in the space provided.
may be subject to backup withholding include interest,
dividends, broker and barter exchange transactions, rents,
Other entities. Enter your business name as shown on
royalties, nonemployee pay, and certain payments from
required federal tax documents on the “Name” line. This
fishing boat operators. Real estate transactions are not
name should match the name shown on the charter or other
subject to backup withholding.
legal document creating the entity. You may enter any
business, trade, or DBA name on the “Business name” line.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make
Note. You are requested to check the appropriate box for
the proper certifications, and report all your taxable interest
your status (individual/sole proprietor, corporation, etc.).
and dividends on your tax return.
Exempt From Backup Withholding
Payments you receive will be subject to backup
withholding if:
If you are exempt, enter your name as described above and
1. You do not furnish your TIN to the requester,
check the appropriate box for your status, then check the
“Exempt from backup withholding” box in the line following
2. You do not certify your TIN when required (see the Part
the business name, sign and date the form.
II instructions on page 4 for details),
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