Form COG- W-9 (Rev. Dec 2015)
Part III: Direct Payment Information
Instructions
Attach verification of financial institution &
account. Acceptable verification
business name or individual’s name, account
number and bank’s routing number imprinted on
the document. Verification can be in the form of:
1. A voided check/photocopy of check
2. Printout of bank statement
3. Or letter from financial institution.
DEPOSIT SLIPS CANNOT BE ACCEPTED
I authorize the City of Gulfport (the City) to directly deposit funds in the financial institution listed below. I
understand that it may take up to 5 days to process this request and that my first check may not be deposited. I will
verify processing with my financial institution by reviewing my statement and emailed deposit advice.
I understand that if funds that I am not entitled are deposited in my account, then the City will initiate a correcting
(debit) entry. I acknowledge that this authorization may be rejected or discontinued by the City at any time. If any of
the above information changes, I understand that it is my responsibility to complete a new enrollment/change form.
If making a change, I understand that if the direct deposit is not stopped before closing an account, the funds will be
returned to the City for distribution, and will result in a delayed check.
I agree to the terms above and would like to be paid via Direct Deposit. Yes No
Name of Financial Institution
Type of Account
Checking Savings
ABA Bank Routing Number (must be 9 digits)
Account Number (NOT including check number)
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Authorized Signature ► Date ►
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City of Gulfport Substitute W-9
Rev. December 2015
Identification Number and Certification
Completed form should be given
to the requesting department.
Name (List legal name, if joint names, list first & circle the name of the person whose identification number or social security number to be entered in Part I.)
Business name (If different from above.)
Check the appropriate box:
Individual/Sole proprietor
Limited Liability Company- Enter tax classification. (C- C Corporation/ S- S Corporation, P- Partnership) ___ Government
Other (Please explain.) ___________________________________________________
number, street, and apt. or suite no. Remittance Address: if different from legal address number, street, and apt. or suite
no..
Phone #: Fax #: Email address:
Part I: Identification Number
IN in the appropriate box.
For individuals, this is your social security number (SSN).
For other entities, it is
your employer identification number (EIN).
Vendors:
Please provide your Privilege/Business License Number.
- -
OR
Employer identification number
-
Privilege/Business License Number
Part II: Certification
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
Services (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 currently a City of Gulfport employee or have been an employee of the City of Gulfport within the previous twelve (12) months:
Yes____ No _____ (check one). My spouse is currently a City of Gulfport employee or has been an employee of the City of Gulfport within the
previous twelve (12) months: Yes____ No _____ (check one). The business identified in this form above _______ does _______ does not (check
one) currently employ someone who is a City of Gulfport employee or has a City employee who has an ownership interest in the business.
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