COMMUNITY COLLEGE SYSTEM OF NH
ALTERNATE W-9 FORM
PLEASE USE THIS FORM TO PROVIDE THE REQUESTED INFORMATION
VENDOR # _________________
(Assigned by CCSNH)
Pursuant to IRS Regulations, you must furnish your Taxpayer Identification Number (TIN) to the State whether or not you are required to file tax returns. If this
number is not provided, you may be subject to a 28% withholding on each payment made to you. To avoid this 28% withholding & to ensure that accurate tax
information is reported to the IRS, A RESPONSE IS REQUIRED.
If a service provider is a part of a GROUP PRACTICE
, it is the group name & TIN which is required on this Alternate W-9.
If the service provider is a SOLE PROPRIETOR, it is the individual name & TIN which is required on this Alternate W-9.
BUSINESS NAME: _____________________________________________________________________________
ADDITIONAL or DBA NAME: ___________________________________________________________________
LEGAL NAME: ________________________________________________________________________________
REMIT ADDRESS: _____________________________________________________________________________
ZIP: STATE: CITY/TOWN: ________________________________________ _____________ ______________
BUSINESS ADDRESS: __________________________________________________________________________
ZIP: STATE: CITY/TOWN: ________________________________________ _____________ ______________
TAXPAYER IDENTIFICATION NUMBER (TIN) as used on IRS tax return
Fed ID # (EIN/FIN): Social Security # (SSN): ______________________ ________________________
PRINCIPAL ACTIVITY
Service Provider Product/Merchandise Provider Other Provider
List the principal type of service, product or other that is provided: ______________________________________________
_______________________________________________________________________________________________
DESIGNATION (select ONLY THOSE which apply to you/your organization as provided to the IRS)
Individual/Sole-Proprietor Partnership/LLP Government
Corporation Estate or Trust Health Care Provider
LLC Non-Profit Legal Services
(attach exemption)
Under penalty of perjury, I declare that the information provided is true, correct & complete, to the best of my knowledge & belief.
NAME & TITLE (print or type): __________________________________________________________________
FAX #:TOLL FREE #: TELEPHONE #: ________________ ________________ _______________________
DATE: SIGNATURE: ___________________________________________ _________________________
PLEASE RETURN WHEN COMPLETED TO: ATTN:
College:
Address:
City, State, Zip:
Telephone #:
Fax #:
