Name (DBA) and Physical Address:
PLEASE COMPLETE AND RETURN TO:
MN Office of Higher Education/TSLRP
1450 Energy Park Drive, St. Paul, MN 55108
FAX: 651-797-1636
Date:
Vendor Number (only list if you have a vendor number
already assigned):
Email Address:
County:
SUBJECT: Request for Taxpayer Information. (Failure to furnish a taxpayer identification number makes you subject
to a penalty of $50.)
The purpose of this form is to obtain or confirm your correct taxpayer name and identification number. Federal and state tax
regulations require that we have this information from recipients of certain payments in order to report such payments to the
Internal Revenue Service on the Form 1099 Return.
Please complete items 1, 2, and 3 below.
1.
Check your tax filing status below and enter your social security number or federal employer identification number. If you
have been issued a separate Minnesota tax identification number, write it in the space provided.
If you have recently applied for a taxpayer number, write "Applied For" in the space for the number.
Sole Proprietorship: Use SSN or FEIN
Corporation: Use FEIN
-- --
SOCIAL SECURITY NUMBER (SSN)
S Corporation
Legal Partnership: Use FEIN
--
FEDERAL EMPLOYER IDENTIFICATION (FEIN)
Tax Exempt Organization: Use FEIN and list the
section number of the IRS code under which you are
claiming exemption:
MINNESOTA TAX I.D. NUMBER (IF APPLICABLE)
Other: Please explain on reverse side and include a
2.
Print the full Legal/Withholding name belonging to the social security number or employer identification number written above.
3.
Certification. Under penalty of perjury, I certify the number shown on this form is my correct taxpayer identification number.
Signature Phone No.: Date
PRIVACY ACT NOTICE - Internal Revenue code Section 6109 requires you to furnish your correct taxpayer
identification number to payers who must file information returns with IRS. IRS uses the numbers for identification
purposes and to help verify the accuracy of your tax return. Payers must generally withhold 28% of taxable interest
and certain other payments to a payee who does not furnish a TIN to a payer.
