Give form to the
requester. Do not
send to the IRS.
Form W-9
Request for Taxpayer
Identification Number and Certification
(Rev. January 2003)
Department of the Treasury
Internal Revenue Service
Name
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. 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
––
or
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
2.
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. 1-2003)
Part I
Part II
Business name, if different from above
Cat. No. 10231X
Check appropriate box:
Under penalties of perjury, I certify that:
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.
Foreign person. If you are a foreign person, use the
appropriate Form W-8 (see Pub. 515, Withholding of Tax on
Nonresident Aliens and Foreign Entities).
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.
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 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.
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.
Pascua Yaqui Tribe
Fax to 520-879-5262
Or mail to: P.O. 11815 Tucson, AZ 85734
