State of Arizona Substitute W-9: Request for Taxpayer Identification Number and Certification
Submit completed form to the State of Arizona Agency with whom you are doing business with for review and authorization.
1
Type of Request (Must select at least ONE)
Change - Select the
type(s) of change from
the following:
New Location
(Additional Address
ID)
New Request
Tax ID Legal Name Entity Type Minority Business Indicator
Main Address
Remittance Address Contact Information
2
Taxpayer Identification Number (TIN) (Provide ONE Only)
TIN
-
OR
SSN
- -
3
Entity Name (As it appears on IRS EIN records, IRS Letter CP575, IRS Letter 147C or Social Security Administration Records, Social Security Card.
If Individual, Sole Proprietor, Single Member LLC, enter First, Middle, Last Name.)
Legal Name
DBA Name
4
Entity Type (Must select ONE of the following)
Individual/Sole Proprietor or Single-Member LLC
Corporation
Partnership
Limited Liability Company (LLC) including Corporations &
Partnerships
The US or any of its political subdivisions or instrumentalities
A state, a possession of the US, or any of their political subdivisions or
instrumentalities
Other: Tax Reportable Entity
Other: Tax Exempt Entity
Description
5
Minority Business Indicator (Must select ONE of the following)
Small Business
Small Business- African American
Small Business- Asian
Small Business - Hispanic
Small Business- Native American
Small Business- Other Minority
Small, Woman Owned Business
Small, Woman Owned Business- African American
Small, Woman Owned Business- Asian
Small, Woman Owned Business- Hispanic
Small, Woman Owned Business- Native American
Small, Woman Owned Business- Other Minority
Woman Owned Business
Woman Owned Business- African American
Woman Owned Business- Asian
Woman Owned Business- Hispanic
Woman Owned Business- Native American
Woman Owned Business- Other Minority
Minority Owned Business- African American
Minority Owned Business- Asian
Minority Owned Business- Hispanic
Minority Owned Business- Native American
Minority Owned Business- Other Minority
Non-Profit, IRC §501(c)
Non-Small, Non-Minority or Non-Woman Owned
Business
Individual, Non-Business
6
Veteran Owned Business
NOYES
7
Entity Address
Main Address (Where tax information and general correspondence is to be mailed)
Address Line 1
Address Line 2
City State Zip code
Remittance Address (Where payment is to be mailed)
Same as Main
Address Line 1
Address Line 2
City State Zip code
8
Vendor Contact Information
Name Title
Phone Ext. Fax Email
9
Exemption from Backup Withholding and FATCA Reporting: Complete this section if it is applicable to you. See instructions for more details
Exemption Code for Backup Withholding Exemption Code for FATCA Reporting
10
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct Taxpayer Identification Number, 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 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 US citizen or other US person, and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
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.
Signature Print Name Date
GAO-W-9 (10/2019)
click to sign
signature
click to edit
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