Rev. 3/30/12
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Kentucky Community and Technical College System
300 North Main Street, Versailles, KY 40383
College Contact:
College Contact Email:
College Contact Ph:
College Contact Fax:
To avoid Internal Revenue Service (IRS) mandated backup withholding KCTCS is required to obtain your Taxpayer Identification Number (TIN) for reporting
income paid to you or your organization. KCTCS uses a Substitute W-9 Form to obtain certification of your TIN and retains this information in its secure
payee/vendor database. This form may be completed online and then printed for signature. Tab to fields and populate with your information. New Vendors
must complete the entire form. Existing Vendor’s may the complete shaded area of form. New and updated forms must be signed and dated.
New Vendor (complete entire form) Changes to existing vendor (shaded area only)
Federal Tax ID #: (Required) ________________________________ TIN/EIN SSN
Legal Name used for purposes of IRS reporting
Business Name (if different from name used for purposes of IRS reporting)
Does your business accept credit Cards? Yes No If yes, Visa MC Other: ___________________
Type of Business (Required):
Corporation Government Entity Foreign Nonresident Individual
Partnership Foreign Entity (other than individual) Limited Liability Company
Non Profit/501(c) Entity US Agent of Foreign Person/Entity Individual/Sole Proprietor (US Citizen)
Exempt from backup withholding
Other (Please Explain):__________________________________________ _________________ ___________ _________
Business Classification (Required - Select only one Does not apply to publically traded entities):
American Indian
Other (explain):
Disadvantaged Business Enterprise/DBE
Defined as a business at least 51% owned by at least one differently-
abled, socially, or economically disadvantaged individual as defined by
Federal law.
Disadvantaged Veteran Owned Business/DVOB
Defined as a business at least 51% owned and operated by a service
veteran with a service-related disability of at least 10 percent.
Other (Explain):
Under penalties of perjury, I certify that:
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 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
I am a U.S. person (including a U.S. resident alien).
Sign Here
Signature of US Person
Printed Name:
Rev. 3/30/12
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Purchase Order
Purchase Order Information
Preferred Method of Receiving Purchase Orders: Email Fax Check if there is a change to your Purchase order address
Vendor Name
(if different from above)
Order to Address
Sales Contact Name
E-mail for
Sales Contact Phone
Fax for PO
Purchase Address Change
Remittance Address as it appears on your invoice Check if there is a change to your remit address
Vendor Name
(if different from above)
Remit to Address
Remit to Contact Name
Remit to Phone
Remit to Address Change
Wherever possible we desire to replace check payments with an electronic payment (ACH - direct deposit transfer). In order to switch your payment type if
already established from paper check to electronic transfer we will need your bank account information entered on this substitute W-9 form. Your email
address will only be used to notify you when an electronic payment is issued, to notify you of the issuance of a purchase order, or to notify you of other official
business correspondence. Your e-mail and/or banking information will not be shared or distributed outside KCTCS’ Business Services Division and will be used
solely for KCTCS business applications.
Direct Deposit Information (All fields are required to receive ACH electronic direct deposit payments)
Name on Bank Account:
Bank Name (include branch name if applicable):
Bank Routing Number (9-digit ABA #): Bank Account Number:
Mark only one (should match information noted above): Checking: Savings:
E-mail address -- Please print LEGIBLY -- Required for electronic notification of payment to your bank account.
Mark if this is a:
Establishment of a new direct deposit Change of existing direct deposit
Email change only New email address to where payment notification to be sent:
I hereby authorize and request KCTCS to initiate credit entries for payment to my account. If necessary, a debit entry may be made in accordance with National
Automated Clearing House Association (NACHA) rules reversing a credit entry made in error at the financial institution named. The electronic payment data
remains in effect until withdrawn by written notification to KCTCS, 300 North Main Street, Versailles, KY 40383.
PRINTED NAME Authorized Signature Date