Give form to the
Request for Taxpayer
requester. Do NOT
Identification Number and Certification
(Rev. October 2007)
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 (.)
Check appropriate box:
Limited Liability Company Enter the tax classification (D=disregarded entity, C=corporation, P=partnership►
Exempt payee (from backup withholding)
Other (see instructions)
Address (number, street, and apt. or suite no.)
Requestors name and address (optional)
UNIVERSITY OF WISCONSIN
City, state, and ZIP code
List account number(s) here (optional)
Taxpayer Identification Number
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 Part I instructions on page 3. For other entities, it is your
employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose
Employer identification number
number to enter.
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. citizen or other U.S. person (defined below)
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.
Signature of US Person►
TREATY-BASED POSITION DISCLOSURE UNDER SECTION 6114 OR 7701(b)
I am a resident alien of the United States.
Enter the specific treaty position relied on: Treaty Country _________________ Article(s) __________________
The internal revenue code provisions overruled or modified by the treaty-based return position are IRC 61; 871(b).
I entered the United States on _______________ on a _______________ visa. I am currently on a ________________ visa.
Under the residency rules of IRC 7701(b) I have passed the substantial presence test.
The treaty between ___________________ and the United States allows an exclusion of _____________ income, with specific
exceptions to the saving clause. I am able to take a total exclusion amount of __________________.