Fax Cover Sheet - Upmc Health Plan, Form W-9 - Request For Taxpayer Identification Number And Certification - Department Of Treasury Page 5
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54
Form W-9 (Rev. 11-2005)
Page
Part II. Certification
What Name and Number To Give the
Requester
To establish to the withholding agent that you are a U.S.
person, or resident alien, sign Form W-9. You may be
For this type of account:
Give name and SSN of:
requested to sign by the withholding agent even if items 1, 4,
and 5 below indicate otherwise.
1. Individual
The individual
For a joint account, only the person whose TIN is shown in
2. Two or more individuals (joint
The actual owner of the account
Part I should sign (when required). Exempt recipients, see
account)
or, if combined funds, the first
1
individual on the account
Exempt From Backup Withholding on page 2.
2
3. Custodian account of a minor
The minor
Signature requirements. Complete the certification as
(Uniform Gift to Minors Act)
indicated in 1 through 5 below.
1
4. a. The usual revocable
The grantor-trustee
1. Interest, dividend, and barter exchange accounts
savings trust (grantor is
opened before 1984 and broker accounts considered
also trustee)
active during 1983. You must give your correct TIN, but you
1
b. So-called trust account
The actual owner
do not have to sign the certification.
that is not a legal or valid
trust under state law
2. Interest, dividend, broker, and barter exchange
3
5. Sole proprietorship or
The owner
accounts opened after 1983 and broker accounts
single-owner LLC
considered inactive during 1983. You must sign the
certification or backup withholding will apply. If you are
For this type of account:
Give name and EIN of:
subject to backup withholding and you are merely providing
3
6.
Sole proprietorship or
The owner
your correct TIN to the requester, you must cross out item 2
single-owner LLC
in the certification before signing the form.
4
7.
A valid trust, estate, or
Legal entity
3. Real estate transactions. You must sign the
pension trust
certification. You may cross out item 2 of the certification.
8.
Corporate or LLC electing
The corporation
corporate status on Form
4. Other payments. You must give your correct TIN, but
8832
you do not have to sign the certification unless you have
been notified that you have previously given an incorrect TIN.
9.
Association, club, religious,
The organization
charitable, educational, or
“Other payments” include payments made in the course of
other tax-exempt organization
the requester’s trade or business for rents, royalties, goods
10.
Partnership or multi-member
The partnership
(other than bills for merchandise), medical and health care
LLC
services (including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat
11.
A broker or registered
The broker or nominee
nominee
crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
12.
Account with the Department
The public entity
of Agriculture in the name of
5. Mortgage interest paid by you, acquisition or
a public entity (such as a
abandonment of secured property, cancellation of debt,
state or local government,
qualified tuition program payments (under section 529),
school district, or prison) that
IRA, Coverdell ESA, Archer MSA or HSA contributions or
receives agricultural program
distributions, and pension distributions. You must give
payments
your correct TIN, but you do not have to sign the
certification.
1
List first and circle the name of the person whose number you furnish. If
only one person on a joint account has an SSN, that person’s number must
be furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
3
You must show your individual name and you may also enter your business
or “DBA” name on the second name line. You may use either your SSN or
EIN (if you have one). If you are a sole proprietor, IRS encourages you to
use your SSN.
4
List first and circle the name of the legal trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account title.) Also see Special rules
regarding partnerships on page 1.
Note. If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS
uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat
terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
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