Authorized Signature,
Title & Current Date*
State of Maine Substitute W-9 & Vendor Authorization Form
PURPOSE: To establish or update an account with the State of Maine's accounting system.
Complete this form if: 1) You will receive payment from the State of Maine, and/or 2) You are a vendor who
provides services or goods to the State of Maine.
This form replaces the IRS W-9 form per the IRS W-9 language; "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."
Legal Name*
Alias/DBA
C/OAddress
City/State/Zip
Phone
TAXPAYER ID NUMBER* (TIN) (Provide ONE only)
Social Security Number (SSN) Federal Employer ID Number (FEIN)
OR
LEGAL NAME (Must provide: Legal name filed with IRS tied to the ID number, SSN=first & last name/FEIN=business name)
TYPE OF REQUEST*: (Must select one.)
New
Request
New Location/Additional
Entry
Change (Choose)
Legal Name DBA Name
Payment Address
Ordering Address
Contact Info
Classification *
Organization Type *
Other Gov't
Sole Proprietorship Corporation
Foreign (W8 required)
State Gov't
Individual
Nonresident Alien
Other
Trust
Partnership
Individual
choose ONE
choose ONE
OR
Payment Address*
Phone
C/O
City/State/Zip
Address
Procurement/Physical Address*
Phone
Email
Name
Contact*
Billing Address
Admin. Address
Ext
Ext
Phone
Email
Name
Contact*
Contact's Phone #
Agency Contact Person Name & Title
State Agency & SHS #
OFFICE USE ONLY
Information on State Agency Submitting Vendor Form
OFFICE USE ONLY
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 witholding, 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 U. S. citizen or other U. S. person (defined by the IRS). Ref: www.irs.gov
Account/Client/Provider Number (if known)
Vendor Customer Number (if known) VC#/VS#
Other Info
Send me Email notifications of DD/EFT
(requires Direct Deposit/EFT form to be completed)
My
is the same.
is the same.
Admin. Address
Billing Address
My
Company
ME W9 V3 05/03/12
All items with an asterisk ( * ) must be completed.
RETURN TO:
by mail
to the agency who
requested the form
or sent it to you, or
the agency you're
doing business with.
(ie.. DHHS/Labor/
DEP/Education/etc)
