SUBSTITUTE W-9 & VENDOR INFORMATION FORM. GIVE FORM TO THE REQUESTER
DO NOT SEND TO IRS
Upload completed form to: SHUMFT
Forms can also be mailed or faxed to:
NEW VENDOR EXISTING VENDOR
5151 Park Avenue, Fairfield, CT 06825, Attn: Purchasing, Fax (203) 365-7609
FOREIGN ENTITIES: DO NOT FILL OUT THIS FORM
PART I: VENDOR INFORMATION (Please print or type information ) CONTACT YOUR SHU CONTACT FOR INFORMATION
1
2
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4
Exemptions(codes apply only to certain entities, not individuals)
S Corporation Trustee/estate
Exemption payee code (if any)
proprietor or single-member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
Exemption from FATCA
Note . For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above
reporting code(if any)
for the tax classification of the single-member owner.
Other
5
BUSINESS ADDRESS(no., street, and apt. or ste#) REMITTANCE ADDRESS(no., street, and apt. or ste#)
7 Taxpayer Identification Number (TIN)
SOCIAL SECURITY NUMBER
OR EMPLOYER IDENTIFICATION NUMBER
CITY, STATE and POSTAL CODE CITY, STATE and POSTAL CODE
8
SACRED HEART UNIVERSITY STAFF CONTACT NAME
SACRED HEART UNIVERSITY STAFF CONTACT EMAIL
6
PURCHASE ORDER FAX NUMBER
SACRED HEART UNIVERSITY STAFF CONTACT PHONE
9 Sacred Heart University Prefers Electronic Forms of Payment:
12
Are you a current Sacred Heart University Student?
Do you accept credit card payments? Do you accept other electronic payments?
YES NO YES NO YES NO
10 Are the services for which payments are received reported for the purpose of self employment tax?
13
Are you a current Sacred Heart University Employee?
YES NO YES NO
11 Do you have a Conflict of Interest with Sacred Heart University, including but not limited to relatives employed by Sacred Heart?
YES NO
If YES, please specify conflict:________________________________________
PART II: Certification - REQUIRED
Under penalties of perjury, I certify that:
1 The number shown on this form is my correct tax identification number (or I am waiting for a number to be issued to me); and
2 I am not subject to backup withholding becaus
e: 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
3 I am a U.S. citizen or other U.S. person; and
4 The FATCA code(s) entered on this form (if any) indicating that I
am exempt from FATCA reporting is correct.
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 o
f
secured property, cancellation of debt, contributions to an individ
ual 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.
SIGN HERE: (must be an original signature - we cannot accept typed or electronic signatures)
PART III: Contact Information - Individual Authorized to Represent the Vendor NOT FROM SACRED HEART UNIVERSITY
Vendor Contact Person Name Title
Contact Person Email Address Contact Person Phone Number
4/13/2020
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION
NAME (as shown on your income tax). Name is required on this line; do not leave this line blank.
Business name/disregarded entity name, if different from above
Individual/sole C Corporation Partnership
PURCHASE ORDER EMAIL
Signature Date
Print Name
