Fax Cover Sheet - Upmc Health Plan, Form W-9 - Request For Taxpayer Identification Number And Certification - Department Of Treasury Page 4
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53
Form W-9 (Rev. 11-2005)
Page
Generally, individuals (including sole proprietors) are not
Part I. Taxpayer Identification
exempt from backup withholding. Corporations are exempt
Number (TIN)
from backup withholding for certain payments, such as
interest and dividends.
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
Note. If you are exempt from backup withholding, you
your TIN is your IRS individual taxpayer identification number
should still complete this form to avoid possible erroneous
(ITIN). Enter it in the social security number box. If you do
backup withholding.
not have an ITIN, see How to get a TIN below.
Exempt payees. Backup withholding is not required on any
If you are a sole proprietor and you have an EIN, you may
payments made to the following payees:
enter either your SSN or EIN. However, the IRS prefers that
1. An organization exempt from tax under section 501(a),
you use your SSN.
any IRA, or a custodial account under section 403(b)(7) if the
If you are a single-owner LLC that is disregarded as an
account satisfies the requirements of section 401(f)(2),
entity separate from its owner (see Limited liability company
2. The United States or any of its agencies or
(LLC) on page 2), enter your SSN (or EIN, if you have one). If
instrumentalities,
the LLC is a corporation, partnership, etc., enter the entity’s
3. A state, the District of Columbia, a possession of the
EIN.
United States, or any of their political subdivisions or
Note. See the chart on page 4 for further clarification of
instrumentalities,
name and TIN combinations.
4. A foreign government or any of its political subdivisions,
How to get a TIN. If you do not have a TIN, apply for one
agencies, or instrumentalities, or
immediately. To apply for an SSN, get Form SS-5,
5. An international organization or any of its agencies or
Application for a Social Security Card, from your local Social
instrumentalities.
Security Administration office or get this form online at
Other payees that may be exempt from backup
You may also get this form by
withholding include:
calling 1-800-772-1213. Use Form W-7, Application for IRS
6. A corporation,
Individual Taxpayer Identification Number, to apply for an
ITIN, or Form SS-4, Application for Employer Identification
7. A foreign central bank of issue,
Number, to apply for an EIN. You can apply for an EIN online
8. A dealer in securities or commodities required to register
by accessing the IRS website at and
in the United States, the District of Columbia, or a
clicking on Employer ID Numbers under Related Topics. You
possession of the United States,
can get Forms W-7 and SS-4 from the IRS by visiting
9. A futures commission merchant registered with the
or by calling 1-800-TAX-FORM
Commodity Futures Trading Commission,
(1-800-829-3676).
10. A real estate investment trust,
If you are asked to complete Form W-9 but do not have a
11. An entity registered at all times during the tax year
TIN, write “Applied For” in the space for the TIN, sign and
under the Investment Company Act of 1940,
date the form, and give it to the requester. For interest and
dividend payments, and certain payments made with respect
12. A common trust fund operated by a bank under
to readily tradable instruments, generally you will have 60
section 584(a),
days to get a TIN and give it to the requester before you are
13. A financial institution,
subject to backup withholding on payments. The 60-day rule
14. A middleman known in the investment community as a
does not apply to other types of payments. You will be
nominee or custodian, or
subject to backup withholding on all such payments until you
provide your TIN to the requester.
15. A trust exempt from tax under section 664 or
described in section 4947.
Note. Writing “Applied For” means that you have already
applied for a TIN or that you intend to apply for one soon.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
Caution: A disregarded domestic entity that has a foreign
exempt recipients listed above, 1 through 15.
owner must use the appropriate Form W-8.
IF the payment is for . . .
THEN the payment is exempt
for . . .
Interest and dividend payments
All exempt recipients except
for 9
Broker transactions
Exempt recipients 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
Exempt recipients 1 through 5
and patronage dividends
Generally, exempt recipients
Payments over $600 required
2
1 through 7
to be reported and direct
1
sales over $5,000
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys’ fees; and
payments for services paid by a federal executive agency.
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