Fillable Form 3: 1 2 State of Arizona Substitute (Arizona)

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Form 3: 1 2 State of Arizona Substitute (Arizona)

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State of Arizona Substitute W-9: Request for Taxpayer Identification Number and Certification
Submit completed form to the State of Arizona Agency with whom you are doing business with for review and authorization.
1
Type of Request (Must select at least ONE)
Change - Select the
type(s) of change from
the following:
New Location
(Additional Address
ID)
New Request
Tax ID Legal Name Entity Type Minority Business Indicator
Main Address
Remittance Address Contact Information
2
Taxpayer Identification Number (TIN) (Provide ONE Only)
TIN
-
OR
SSN
- -
3
Entity Name (As it appears on IRS EIN records, IRS Letter CP575, IRS Letter 147C or Social Security Administration Records, Social Security Card.
If Individual, Sole Proprietor, Single Member LLC, enter First, Middle, Last Name.)
Legal Name
DBA Name
4
Entity Type (Must select ONE of the following)
Individual/Sole Proprietor or Single-Member LLC
Corporation
Partnership
Limited Liability Company (LLC) including Corporations &
Partnerships
The US or any of its political subdivisions or instrumentalities
A state, a possession of the US, or any of their political subdivisions or
instrumentalities
Other: Tax Reportable Entity
Other: Tax Exempt Entity
Description
5
Minority Business Indicator (Must select ONE of the following)
Small Business
Small Business- African American
Small Business- Asian
Small Business - Hispanic
Small Business- Native American
Small Business- Other Minority
Small, Woman Owned Business
Small, Woman Owned Business- African American
Small, Woman Owned Business- Asian
Small, Woman Owned Business- Hispanic
Small, Woman Owned Business- Native American
Small, Woman Owned Business- Other Minority
Woman Owned Business
Woman Owned Business- African American
Woman Owned Business- Asian
Woman Owned Business- Hispanic
Woman Owned Business- Native American
Woman Owned Business- Other Minority
Minority Owned Business- African American
Minority Owned Business- Asian
Minority Owned Business- Hispanic
Minority Owned Business- Native American
Minority Owned Business- Other Minority
Non-Profit, IRC §501(c)
Non-Small, Non-Minority or Non-Woman Owned
Business
Individual, Non-Business
6
Veteran Owned Business
NOYES
7
Entity Address
Main Address (Where tax information and general correspondence is to be mailed)
Address Line 1
Address Line 2
City State Zip code
Remittance Address (Where payment is to be mailed)
Same as Main
Address Line 1
Address Line 2
City State Zip code
8
Vendor Contact Information
Name Title
Phone Ext. Fax Email
9
Exemption from Backup Withholding and FATCA Reporting: Complete this section if it is applicable to you. See instructions for more details
Exemption Code for Backup Withholding Exemption Code for FATCA Reporting
10
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct Taxpayer Identification Number, 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 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 US citizen or other US person, and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
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 of secured property, cancellation of
debt, contributions to an individual 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.
Signature Print Name Date
GAO W-9 & ACH (10/2018)
The State of Arizona Substitute W-9 Form Instructions
The State of Arizona (State), like all organizations that file an information return with the IRS, must obtain your correct
Taxpayer Identification Number (TIN) to report income paid to you or your organization. The State uses the Substitute W-9
Form to obtain certification of your TIN in order to ensure accuracy of information contained in its payee/vendor system and
to avoid Backup Withholding as mandated by the IRS. According to IRS regulations, the State must withhold 28% of all
payments if a vendor/payee fails to provide the State its certified TIN. The Substitute Form W-9 certifies a vendor/payee's TIN.
Any vendor/payee who wishes to do business with the State must complete the Substitute W-9 Form.
Part 1 - Type of Request: Select only one.
Part 2 - Taxpayer Identification Number (TIN): Enter your nine-digit TIN. The TIN is either your nine-digit Social Security
Number (SSN) assigned by the Social Security Administration (SSA) or Employer Identification Number (EIN) assigned by the
Internal Revenue Service (IRS).
Part 3 - Entity Name: Enter the legal name as it appears on IRS EIN records, IRS Letter CP575, IRS Letter 147C or Social Security
Administration Records, Social Security Card. If Individual, Sole Proprietor, Single Member LLC, enter First, Middle, Last Name.
Enter your DBA in the designated line if applicable.
Part 4 - Entity Type: Select only one for TIN given.
Part 5 - Minority Business Indicator: Select only one for TIN given.
Part 6 - Veteran Owned Business: Select only one for TIN given.
Part 7 - Entity Address: List the locations for tax reporting purposes and where payments should be mailed.
Part 8 - Entity Contact Information: List the contact information.
Part 9 - Backup Withholding and FATCA Exemptions: If you are exempt from Backup Withholding and/or FATCA reporting,
enter in the Exemptions box, any code(s) that may apply to you.
Backup Withholding Exemption Codes: Generally, Individuals (including Sole Proprietors) are not exempt from Backup Withholding. Additionally, Corporations
are not exempt from Backup Withholding when supplying legal or medical services. If you do not fall under the categories below, leave this field blank. The
following codes identify payees that are exempt from Backup Withholding:
Code 1: An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b) (7) if the account satisfies the requirements of
section 401(f) (2)
Code 2: The United States or any of its agencies or instrumentalities
Code 3: A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or Instrumentalities
Code 4: A foreign government or any of its political subdivisions, agencies, or instrumentalities
Code 5: A corporation
Code 6: A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States Code 7: A
futures commission merchant registered with the Commodity Futures Trading Commission
Code 8: A real estate investment trust
Code 9: An entity registered at all times during the tax year under the Investment Company Act of 1940
Code 10: A common trust fund operated by a bank under section 584(a)
Code 11: A financial institution
Code 12: A middleman known in the investment community as a nominee or custodian
Code 13: A trust exempt from tax under section 664 or described in section 4947
FATCA Exemption Codes: The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form
for accounts maintained outside of the United States by certain foreign financial institutions. If you are only submitting this form for an account you hold in the
United States, leave this field blank. The following codes identify payees that are exempt from FATCA Reporting:
Code A: An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a) (37)
Code B: The United States or any of its agencies or instrumentalities
Code C: A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities
Code D: A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472-1(c)(1)(i)
Code E: A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c) (1) (i)
Code F: A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is
registered as such under the laws of the United States or any state
Code G: A real estate investment trust
Code H: A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of
1940
Code I: A common trust fund as defined in section 584(a)
Code J: A bank as defined in section 581 Code K: A broker
Code L: A trust exempt from tax under section 664 or described in section 4947(a) (1)
Code M: A tax-exempt trust under a section 403(b) plan or section 457(g) plan
Part 10 - Certification: Please sign, date and provide preparer's name in appropriate space.
GAO W-9 & ACH (10/2018)
1
Request Type (Select only ONE)
New
Change
Cancellation,
Cancellation Reason:
2
Taxpayer Identification Number (TIN)
EIN
-
OR
SSN
- -
3
Legal Name, Address and Contact Information
Name
Phone
Ext
Address City State Zip Code
4
Change Information - FOR CHANGE REQUEST ONLY
Changing:
Financial Institution
Authorized Signers
Account Type
Account Number
Previous Financial Institution:
Previous Account Type:
Checking Savings
Previous Account Number:
5
AUTHORIZATION FOR NEW SETUP, CHANGE(S) OR CANCELLATION
Pursuit to A.R.S. Sec. 35-185, I authorize the Arizona Department of Administration (ADOA), General Accounting Office (GAO) to process payments owed to me by the
State of Arizona (State) via Automated Clearing House (ACH) deposits. The State shall deposit the ACH payments in the financial institution and account designated
below. I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or made
impossible, and my electronic payments may be posted to the wrong account.
I authorize the State to withdraw from the designated account all amounts deposited electronically in error in accordance with NACHA rules and timelines.
If the designated account is closed or has an insufficient balance to allow withdrawal, then I authorize the State to withhold any payment owed to me by the State
until the erroneously deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to the ADOA-GAO.
The change or revocation is effective on the day the ADOA-GAO processes the request.
I certify that I have read and agree to comply with the State's rules governing payments and electronic transfers as they exist on the date of my signature on this form
or as subsequently adopted, amended, or repealed. I consent to, and agree to, comply with these rules even if they conflict with this authorization form.
I authorize the State to stop making electronic transfers to my account without advance notice.
I certify that I am authorized to contract for the entity receiving deposits pursuant to this agreement and that all information provided is accurate.
Name
Authorized Signature (Required)
______________________________________
Title
Date
Additional Authorized Signers
Name
Authorized Signature
______________________________________
Title
Date
Name
Authorized Signature
______________________________________
Title
Date
Addendum record format
CTX CCD+ Detailed ACH payment can also be viewed online at http://venpay.gao.azdoa.gov.
6
Financial Institution
Financial Institution Name
Phone Ext
Address (Optional) City State Zip Code
Routing Number Account Number
Account Type
Checking Savings
7
GAO USE ONLY
Verified by and date Entered by and date Vendor # Address ID
Entity Contact Verified by
Input verified & approved by Doc Number Entered
GAO W-9 & ACH (10/2018)
Original form is preferred. Please contact Vendor.PayAutomation@azdoa.gov if you have questions about the form or setup process.
DO NOT SUBMIT COMPLETED FORM TO STATE OF ARIZONA AGENCIES. SUBMIT COMPLETED FORM TO:
DEPARTMENT OF ADMINSTRATION/GENERAL ACCOUNTING OFFICE
ATTN: VENDOR SETUP
100 N 15TH AVE, STE 302
PHOENIX, AZ 85007
STATE OF ARIZONA ACH AUTHORIZATION FORM
STATE OF ARIZONA ACH AUTHORIZATION FORM INSTRUCTIONS
ORIGINAL FORM IS PREFERRED. ANY REQUEST FOR ACH PAYMENTS INTO MULTIPLE ACH ACCOUNTS WILL BE REVIEWED AND
APPROVED ON A CASE-BY-CASE BASIS.
DO NOT SUBMIT COMPLETED FORM TO STATE OF ARIZONA AGENCIES.
SUBMIT COMPLETED FORM TO THE GENERAL ACCOUNTING OFFICE FOR REVIEW AND SETUP.
SUBMIT COMPLETED FORM TO:
DEPARTMENT OF ADMINISTRATION/GENERAL ACCOUNTING OFFICE
ATTN: VENDOR SETUP
100 N 15
TH
AVE, STE 302 PHOENIX, AZ 85007
Part 1 - Request Type: Select one.
Part 2 - Taxpayer Identification Number (TIN): Enter your nine-digit TIN. The TIN is either your nine-
digit Employer Identification Number (EIN) assigned by the Internal Revenue Service (IRS) or Social
Security Number (SSN) assigned by the Social Security Administration (SSA), whichever one is
associated with the Legal Name in Part 3.
Part 3 - Legal Name, Address, and Contact Information: Complete all information.
Part 4 - Change Information (Change Request Only): Check all boxes that correspond to the account
information being changed.
Part 5 - Authorization: List at least one authorized signer and up to two additional authorized signers.
Only an authorized signer is able to authorize new setup and changes.
Part 6 - Financial Information: Complete all information. Address is optional.
Part 7 - General Accounting Office Use Only: Do not complete.
GAO W-9 & ACH (10/2018)
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Form 3: 1 2 State of Arizona Substitute (Arizona)

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Completed 12 August 2020

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