Rogers State University
Substitute IRS Form W‐
9
REQUEST FOR TAXPAYER IDENTIFICATION AND
CERTIFICATION
PRIVACY ACT
STATEMENT
Section 6109 of the Internal Revenue Code requires you to give your correct Taxpayer Identification Number (TIN) to persons who must file information returns
with
the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property,
cancellation of debt, or contributions you made to an IRA. The IRS will use the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation and to cities, states, and the District of Columbia to carry out
their tax laws. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable interest, dividend, and
certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
Name (As shown on your income tax return)
Business Name (if different from above) Exempt From Backup Withholding
‘Remit to’ Address (Number, Street, Apt. or Suite No.)
City, State 9 Digit Zip Code (REQUIRED)
SECTION I – TAXPAYER ID NUMBER, PAYEE TYPE, AND BUSINESS OWNERSHIP TYPE
TAXPAYER ID NUMBER
Enter your Taxpayer Identification Number (TIN) in the appropriate box. For individuals, this is your Social Security Number
(SSN). For other entities, it is your Employer Identification Number (EIN).
Employer Identification Number (EIN)
Social Security Number (SSN)
(Please check only one box in each column)
PAYEE TYPE BUSINESS OWNERSHIP TYPE
Individual Sole Proprietorship
Federal Government Agency Partnership
State, Local Government Agency Corporation
Law Firm or Practice Government Agency
Legal Service Provider Trust
Foreign/Non‐resident
(Provide the appropriate Form W‐8) Tax Exempt/Non‐Profit
Other (Please Explain)
Other (Please Explain)
CERTIFICATION INSTRUCTIONS – You must cross out item 2, below, if you have been notified by the IRS that you are
currently subject to backup withholding because of underreporting of interest or dividends on your tax return. For real estate
transactions, item 2 does not apply. For mortgage interest paid, the acquisition or abandonment of secured property,
cancellation of debt, contributions to an IRA, and generally, payments other than interest and dividends, you are not required
to sign the Certification, but you must provide your correct TIN.
SECTION 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 IRS that I
am subject to backup withholding as a result of failure to report all interest and dividends, or (c) the IRS has notified me that I am no longer
subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien)
The Internal Revenue Service does not require your consent to an provision of this document other than the certifications required to
avoid backup withholding.
Signature of U.S. Person Title Date
Name (Please Print) Telephone Number Fax Number
Fax to RSU Purchasing Department at (9
18) 343‐7817.
