Fill - Free fillable Form W-9: Request for Taxpayer Action Date Signature (City of Worcester) PDF form

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 1 of 4

MARGINS: TOP 13mm (

⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216mm (8

⁄2 ")  279mm (11")

PERFORATE: (NONE)

Give form to the

requester. Do not

send to the IRS.

Form W-9

Request for Taxpayer

Identification Number and Certification

(Rev. November 2005)

Department of the Treasury

Internal Revenue Service

Name (as shown on your income tax return)

List account number(s) here (optional)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Print or type

See Specific Instructions on page 2.

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid

backup withholding. For individuals, this is your social security number (SSN). However, for a resident

alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is

your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Social security number

––

Requester’s name and address (optional)

Employer identification number

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose

number to enter.

–

Certification

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

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 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

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. (See the instructions on page 4.)

Sign

Here

Signature of

U.S. person

䊳

Date

䊳

Purpose of Form

Form W-9 (Rev. 11-2005)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

TLS, have you

transmitted all R

text files for this

cycle update?

Date

Action

Revised proofs

requested

Date Signature

O.K. to print

U.S. person. Use Form W-9 only if you are a U.S. person

(including a resident alien), to provide your correct TIN to the

person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are

waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a

U.S. exempt payee.

3. I am a U.S. person (including a U.S. resident alien).

A person who is required to file an information return with the

IRS, must obtain your correct taxpayer identification number

(TIN) to report, for example, income paid to you, real estate

transactions, mortgage interest you paid, acquisition or

abandonment of secured property, cancellation of debt, or

contributions you made to an IRA.

Individual/

Sole proprietor

Corporation

Partnership

Other

䊳

Exempt from backup

withholding

Note. If a requester gives you a form other than Form W-9 to

request your TIN, you must use the requester’s form if it is

substantially similar to this Form W-9.

● An individual who is a citizen or resident of the United

States,

● A partnership, corporation, company, or association

created or organized in the United States or under the laws

of the United States, or

● Any estate (other than a foreign estate) or trust. See

Regulations sections 301.7701-6(a) and 7(a) for additional

information.

For federal tax purposes, you are considered a person if you

are:

In 3 above, if applicable, you are also certifying that as a

U.S. person, your allocable share of any partnership income

from a U.S. trade or business is not subject to the

withholding tax on foreign partners’ share of effectively

connected income.

Special rules for partnerships. Partnerships that conduct a

trade or business in the United States are generally required

to pay a withholding tax on any foreign partners’ share of

income from such business. Further, in certain cases where a

Form W-9 has not been received, a partnership is required to

presume that a partner is a foreign person, and pay the

withholding tax. Therefore, if you are a U.S. person that is a

partner in a partnership conducting a trade or business in the

United States, provide Form W-9 to the partnership to

establish your U.S. status and avoid withholding on your

share of partnership income.

The person who gives Form W-9 to the partnership for

purposes of establishing its U.S. status and avoiding

withholding on its allocable share of net income from the

partnership conducting a trade or business in the United

States is in the following cases:

● The U.S. owner of a disregarded entity and not the entity,

Print Form

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 2 of 4

MARGINS: TOP 13 mm (

⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (8

⁄2")  279 mm (11")

PERFORATE: (NONE)

Form W-9 (Rev. 11-2005) Page 2

Sole proprietor. Enter your individual name as shown on

your income tax return on the “Name” line. You may enter

your business, trade, or “doing business as (DBA)” name on

the “Business name” line.

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Other entities. Enter your business name as shown on

required federal tax documents on the “Name” line. This

name should match the name shown on the charter or other

legal document creating the entity. You may enter any

business, trade, or DBA name on the “Business name” line.

If the account is in joint names, list first, and then circle,

the name of the person or entity whose number you entered

in Part I of the form.

Limited liability company (LLC). If you are a single-member

LLC (including a foreign LLC with a domestic owner) that is

disregarded as an entity separate from its owner under

Treasury regulations section 301.7701-3, enter the owner’s

name on the “Name” line. Enter the LLC’s name on the

“Business name” line. Check the appropriate box for your

filing status (sole proprietor, corporation, etc.), then check

the box for “Other” and enter “LLC” in the space provided.

Specific Instructions

Name

Exempt From Backup Withholding

5. You do not certify to the requester that you are not

subject to backup withholding under 4 above (for reportable

interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup

withholding. See the instructions below and the separate

Instructions for the Requester of Form W-9.

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 penalty.

Criminal penalty for falsifying information. Willfully

falsifying certifications or affirmations may subject you to

criminal penalties including fines and/or imprisonment.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN

to a requester, you are subject to a penalty of $50 for each

such failure unless your failure is due to reasonable cause

and not to willful neglect.

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.

If you are an individual, you must generally enter the name

shown on your income tax return. However, if you have

changed your last name, for instance, due to marriage

without informing the Social Security Administration of the

name change, enter your first name, the last name shown on

your social security card, and your new last name.

If you are exempt, enter your name as described above and

check the appropriate box for your status, then check the

“Exempt from backup withholding” box in the line following

the business name, sign and date the form.

4. The IRS tells you that you are subject to backup

withholding because you did not report all your interest and

dividends on your tax return (for reportable interest and

dividends only), or

3. The IRS tells the requester that you furnished an

incorrect TIN,

2. You do not certify your TIN when required (see the Part

II instructions on page 4 for details),

You will not be subject to backup withholding on payments

you receive if you give the requester your correct TIN, make

the proper certifications, and report all your taxable interest

and dividends on your tax return.

1. You do not furnish your TIN to the requester,

What is backup withholding? Persons making certain

payments to you must under certain conditions withhold and

pay to the IRS 28% of such payments (after December 31,

2002). This is called “backup withholding.” Payments that

may be subject to backup withholding include interest,

dividends, broker and barter exchange transactions, rents,

royalties, nonemployee pay, and certain payments from

fishing boat operators. Real estate transactions are not

subject to backup withholding.

Payments you receive will be subject to backup

withholding if:

If you are a nonresident alien or a foreign entity not subject

to backup withholding, give the requester the appropriate

completed Form W-8.

Example. Article 20 of the U.S.-China income tax treaty

allows an exemption from tax for scholarship income

received by a Chinese student temporarily present in the

United States. Under U.S. law, this student will become a

resident alien for tax purposes if his or her stay in the United

States exceeds 5 calendar years. However, paragraph 2 of

the first Protocol to the U.S.-China treaty (dated April 30,

1984) allows the provisions of Article 20 to continue to apply

even after the Chinese student becomes a resident alien of

the United States. A Chinese student who qualifies for this

exception (under paragraph 2 of the first protocol) and is

relying on this exception to claim an exemption from tax on

his or her scholarship or fellowship income would attach to

Form W-9 a statement that includes the information

described above to support that exemption.

Note. You are requested to check the appropriate box for

your status (individual/sole proprietor, corporation, etc.).

4. The type and amount of income that qualifies for the

exemption from tax.

5. Sufficient facts to justify the exemption from tax under

the terms of the treaty article.

Nonresident alien who becomes a resident alien.

Generally, only a nonresident alien individual may use the

terms of a tax treaty to reduce or eliminate U.S. tax on

certain types of income. However, most tax treaties contain a

provision known as a “saving clause.” Exceptions specified

in the saving clause may permit an exemption from tax to

continue for certain types of income even after the recipient

has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an

exception contained in the saving clause of a tax treaty to

claim an exemption from U.S. tax on certain types of income,

you must attach a statement to Form W-9 that specifies the

following five items:

1. The treaty country. Generally, this must be the same

treaty under which you claimed exemption from tax as a

nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that

contains the saving clause and its exceptions.

Also see Special rules regarding partnerships on page 1.

Foreign person. If you are a foreign person, do not use

Form W-9. Instead, use the appropriate Form W-8 (see

Publication 515, Withholding of Tax on Nonresident Aliens

and Foreign Entities).

● The U.S. grantor or other owner of a grantor trust and not

the trust, and

● The U.S. trust (other than a grantor trust) and not the

beneficiaries of the trust.

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 3 of 4

MARGINS: TOP 13 mm (

⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (8

⁄2")  279 mm (11")

PERFORATE: (NONE)

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form W-9 (Rev. 11-2005) Page 3

Part I. Taxpayer Identification

Number (TIN)

Enter your TIN in the appropriate box. If you are a resident

alien and you do not have and are not eligible to get an SSN,

your TIN is your IRS individual taxpayer identification number

(ITIN). Enter it in the social security number box. If you do

not have an ITIN, see How to get a TIN below.

How to get a TIN. If you do not have a TIN, apply for one

immediately. To apply for an SSN, get Form SS-5,

Application for a Social Security Card, from your local Social

Security Administration office or get this form online at

www.socialsecurity.gov. You may also get this form by

calling 1-800-772-1213. Use Form W-7, Application for IRS

Individual Taxpayer Identification Number, to apply for an

ITIN, or Form SS-4, Application for Employer Identification

Number, to apply for an EIN. You can apply for an EIN online

by accessing the IRS website at www.irs.gov/businesses and

clicking on Employer ID Numbers under Related Topics. You

can get Forms W-7 and SS-4 from the IRS by visiting

www.irs.gov or by calling 1-800-TAX-FORM

(1-800-829-3676).

If you are asked to complete Form W-9 but do not have a

TIN, write “Applied For” in the space for the TIN, sign and

date the form, and give it to the requester. For interest and

dividend payments, and certain payments made with respect

to readily tradable instruments, generally you will have 60

days to get a TIN and give it to the requester before you are

subject to backup withholding on payments. The 60-day rule

does not apply to other types of payments. You will be

subject to backup withholding on all such payments until you

provide your TIN to the requester.

If you are a sole proprietor and you have an EIN, you may

enter either your SSN or EIN. However, the IRS prefers that

you use your SSN.

If you are a single-owner LLC that is disregarded as an

entity separate from its owner (see Limited liability company

(LLC) on page 2), enter your SSN (or EIN, if you have one). If

the LLC is a corporation, partnership, etc., enter the entity’s

EIN.

Note. See the chart on page 4 for further clarification of

name and TIN combinations.

Note. Writing “Applied For” means that you have already

applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded domestic entity that has a foreign

owner must use the appropriate Form W-8.

9. A futures commission merchant registered with the

Commodity Futures Trading Commission,

10. A real estate investment trust,

11. An entity registered at all times during the tax year

under the Investment Company Act of 1940,

12. A common trust fund operated by a bank under

section 584(a),

13. A financial institution,

14. A middleman known in the investment community as a

nominee or custodian, or

15. A trust exempt from tax under section 664 or

described in section 4947.

THEN the payment is exempt

for . . .

IF the payment is for . . .

All exempt recipients except

for 9

Interest and dividend payments

Exempt recipients 1 through 13.

Also, a person registered under

the Investment Advisers Act of

1940 who regularly acts as a

broker

Broker transactions

Exempt recipients 1 through 5Barter exchange transactions

and patronage dividends

Generally, exempt recipients

1 through 7

Payments over $600 required

to be reported and direct

sales over $5,000

See Form 1099-MISC, Miscellaneous Income, and its instructions.

However, the following payments made to a corporation (including gross

proceeds paid to an attorney under section 6045(f), even if the attorney is a

corporation) and reportable on Form 1099-MISC are not exempt from

backup withholding: medical and health care payments, attorneys’ fees; and

payments for services paid by a federal executive agency.

The chart below shows types of payments that may be

exempt from backup withholding. The chart applies to the

exempt recipients listed above, 1 through 15.

7. A foreign central bank of issue,

8. A dealer in securities or commodities required to register

in the United States, the District of Columbia, or a

possession of the United States,

Exempt payees. Backup withholding is not required on any

payments made to the following payees:

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),

2. The United States or any of its agencies or

instrumentalities,

3. A state, the District of Columbia, a possession of the

United States, or any of their political subdivisions or

instrumentalities,

4. A foreign government or any of its political subdivisions,

agencies, or instrumentalities, or

5. An international organization or any of its agencies or

instrumentalities.

Other payees that may be exempt from backup

withholding include:

6. A corporation,

Generally, individuals (including sole proprietors) are not

exempt from backup withholding. Corporations are exempt

from backup withholding for certain payments, such as

interest and dividends.

Note. If you are exempt from backup withholding, you

should still complete this form to avoid possible erroneous

backup withholding.

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 4 of 4

MARGINS: TOP 13 mm (

⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (8

⁄2")  279 mm (11")

PERFORATE: (NONE)

Form W-9 (Rev. 11-2005) Page 4

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

What Name and Number To Give the

Requester

Give name and SSN of:For this type of account:

The individual1. Individual

The actual owner of the account

or, if combined funds, the first

individual on the account

2. Two or more individuals (joint

account)

The minor

3. Custodian account of a minor

(Uniform Gift to Minors Act)

The grantor-trustee

4. a. The usual revocable

savings trust (grantor is

also trustee)

1. Interest, dividend, and barter exchange accounts

opened before 1984 and broker accounts considered

active during 1983. You must give your correct TIN, but you

do not have to sign the certification.

The actual owner

b. So-called trust account

that is not a legal or valid

trust under state law

2. Interest, dividend, broker, and barter exchange

accounts opened after 1983 and broker accounts

considered inactive during 1983. You must sign the

certification or backup withholding will apply. If you are

subject to backup withholding and you are merely providing

your correct TIN to the requester, you must cross out item 2

in the certification before signing the form.

The owner

5. Sole proprietorship or

single-owner LLC

Give name and EIN of:

For this type of account:

3. Real estate transactions. You must sign the

certification. You may cross out item 2 of the certification.

A valid trust, estate, or

pension trust

Legal entity

4. Other payments. You must give your correct TIN, but

you do not have to sign the certification unless you have

been notified that you have previously given an incorrect TIN.

“Other payments” include payments made in the course of

the requester’s trade or business for rents, royalties, goods

(other than bills for merchandise), medical and health care

services (including payments to corporations), payments to a

nonemployee for services, payments to certain fishing boat

crew members and fishermen, and gross proceeds paid to

attorneys (including payments to corporations).

The corporationCorporate or LLC electing

corporate status on Form

8832

The organizationAssociation, club, religious,

charitable, educational, or

other tax-exempt organization

5. Mortgage interest paid by you, acquisition or

abandonment of secured property, cancellation of debt,

qualified tuition program payments (under section 529),

IRA, Coverdell ESA, Archer MSA or HSA contributions or

distributions, and pension distributions. You must give

your correct TIN, but you do not have to sign the

certification.

The partnershipPartnership or multi-member

LLC

The broker or nomineeA broker or registered

nominee

10.

The public entityAccount with the Department

of Agriculture in the name of

a public entity (such as a

state or local government,

school district, or prison) that

receives agricultural program

payments

11.

Privacy Act Notice

List first and circle the name of the person whose number you furnish. If

only one person on a joint account has an SSN, that person’s number must

be furnished.

Circle the minor’s name and furnish the minor’s SSN.

You must show your individual name and you may also enter your business

or “DBA” name on the second name line. You may use either your SSN or

EIN (if you have one). If you are a sole proprietor, IRS encourages you to

use your SSN.

List first and circle the name of the legal trust, estate, or pension trust. (Do

not furnish the TIN of the personal representative or trustee unless the legal

entity itself is not designated in the account title.) Also see Special rules

regarding partnerships on page 1.

Note. If no name is circled when more than one name is

listed, the number will be considered to be that of the first

name listed.

Sole proprietorship or

single-owner LLC

The owner

12.

Part II. Certification

For a joint account, only the person whose TIN is shown in

Part I should sign (when required). Exempt recipients, see

Exempt From Backup Withholding on page 2.

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% 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.

To establish to the withholding agent that you are a U.S.

person, or resident alien, sign Form W-9. You may be

requested to sign by the withholding agent even if items 1, 4,

and 5 below indicate otherwise.

Section 6109 of the Internal Revenue Code requires you to provide your correct 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, or Archer MSA or HSA. The IRS

uses 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, the District of Columbia, and U.S.

possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal

and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat

terrorism.

Signature requirements. Complete the certification as

indicated in 1 through 5 below.

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Form W-9: Request for Taxpayer Action Date Signature (City of Worcester)

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