Central Council
Tlingit & Haida Indian Tribes of Alaska
Finance Department
9097 Glacier Hwy
Juneau, Alaska 99801
Fax: 1-888-922-2520 Email: financerequests@ccthita-nsn.gov
Request for Vendor Setup
(This form is used in lieu of the W9 form published by the Internal Revenue
service)
All required forms must be completed and signed before payment is
issued
☐ New ☐ Update
LegalName(asshownonyourtaxreturn) SocialSecurityNumber
BusinessName(ifdifferentfromabove) EIN(forbusinesses)
MailingAddress:
C
ity:
State:
Zip:
TelephoneNumber:
(
)
EmailAddress:
VENDORT
YPE
NonTaxable
1099Vendor(Taxable)
☐ Client ☐ Non‐Profit
☐ Employee ☐ Corporation
☐ CouncilDelegate ☐ Government
☐ Other(Specify)
☐ Landlord ☐ DaycareProvider
☐ Attorney ☐ MedicalProvider
☐ SoleProprietor/Partnership
☐ Other(specify)
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 Service (IRS) that I am subject to backup withholding as a result of 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 person (including a US Resident alien)
Certification instructions: You must cross out 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.
Signature Date
Penalties
Failure to furnish TIN: If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50.00 for each
such failure unless your failure is due to a reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding: If you make a false statement with no reasonable basis that
results in no backup withholding, you are subject to a $500.00 penalty.
Criminal penalty for falsifying information: Willfully falsifying certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINs: If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and
criminal penalties.
Finance Only
Debarment Certification: Date
Revised7.23.15FNC
click to sign
signature
click to edit
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