AC 3237-S (Rev. 4/13)
NEW YORK STATE OFFICE OF THE STATE COMPTROLLER
SUBSTITUTE FORM W-9:
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER & CERTIFICATION
TYPE OR PRINT INFORMATION NEATLY. PLEASE REFER TO INSTRUCTIONS FOR MORE INFORMATION.
Part I: Vendor Information
1. Legal Business Name: 2. Business name/disregarded entity name, if different from Legal
Business Name:
3. Entity Type (Check one only):
Individual Sole Proprietor Partnership Limited Liability Co. Corporation Not For Profit
Trusts/Estates Federal, State or Local Government Public Authority Disregarded Entity
Other _______________________________
Exempt
Payee
Part II: Taxpayer Identification Number (TIN) & Taxpayer Identification Type
1. Enter your TIN here: (DO NOT USE DASHES)
See instructions.
2. Taxpayer Identification Type (check appropriate box):
Employer ID No. (EIN) Social Security No. (SSN) Individual Taxpayer ID No. (ITIN) N/A (Non-United States Business Entity)
Part III: Address
1. Physical Address: 2. Remittance Address:
Number, Street, and Apartment or Suite Number Number, Street, and Apartment or Suite Number
City, State, and Nine Digit Zip Code or Country City, State, and Nine Digit Zip Code or Country
Part IV: Certification and Exemption from Backup Withholding
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (TIN), and
2. I am a U.S. citizen or other U.S. person, and
3. (Check one only):
I am not subject to backup withholding. I am (a) 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), or
I am subject to backup withholding. I have been notified by the IRS that I am subject to backup withholding as a result of a
failure to report all interest or dividends, and I have not been notified by the IRS that I am no longer subject to backup withholding.
Sign Here:
_________________________________________________________ ________________________________________ ____________________
Signature Title Date
_________________________________________________________ _________________________ __________________________________
Print Preparer’s Name Phone Number Email Address
Part V: Contact Information – Individual Authorized to Represent the Vendor
Vendor Contact Person: ___________________________________________ Title:_____________________________________________
Contact’s Email Address: ______________________________________________________ Phone Number: ________________________
DO NOT SUBMIT FORM TO IRS SUBMIT FORM TO NYS ONLY AS DIRECTED
AC 3237-S (Rev. 4/13)
NYS Office of the State Comptroller
Instructions for Completing Substitute Form W-9
New York State (NYS) must obtain your correct Taxpayer Identification Number (TIN) to report income
paid to you or your organization. NYS Office of the State Comptroller uses the Substitute Form W-9 to
obtain certification of your TIN in order to ensure accuracy of information contained in its payee/vendor
database and to avoid backup withholding.
1
We ask for the information on the Substitute Form W-9 to
carry out the Internal Revenue laws of the United States. You are required to give us the information.
Any payee/vendor who wishes to do business with New York State must complete the Substitute Form
W-9. Substitute Form W-9 is the only acceptable documentation. We will not accept IRS Form W-9.
Part I: Vendor Information
1. Legal Business Name: For individuals, enter the name of the person who will do business with
NYS as it appears on the Social Security card or other required Federal tax documents. An
organization should enter the name shown on its charter or other legal documents that created
the organization. Do not abbreviate names.
2. Business name/disregarded entity name, if different from Legal Business Name: Enter your
DBA name or another name your entity is known by.
3. Entity Type: Check the Entity Type doing business with New York State.
Part II: Taxpayer Identification Number (TIN) and Taxpayer Identification Type
The TIN provided must match the name in the “Legal Business Name” box to avoid backup withholding.
For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor,
or disregarded entity, refers to IRS W-9 instructions for additional information. For other entities, it is
your employer identification number (EIN). If you do not have a number or if the account is in more than
one name, refer to IRS W-9 instructions for additional information.
1. Taxpayer Identification Number: Enter your nine-digit Social Security Number, Individual
Taxpayer Identification Number (ITIN) or Employer Identification Number (EIN).
2. Taxpayer Identification Type: Check the type of identification number provided.
Part III: Address
1. Physical Address: Enter the location of where your business is physically located.
2. Remittance Address: Enter the address where payments should be mailed.
Part IV: Certification and Exemption from Backup Withholding
Check the appropriate box indicating your exemption status from backup withholding. Individuals and
sole proprietors are not exempt from backup withholding. Corporations are exempt from backup
withholding for certain types of payments. Refer to IRS Form W-9 instructions for additional information.
The signature should be provided by the individual, owner, officer, legal representative, or other
authorized person of the entity listed on the form. Certain exceptions to the signature requirement are
listed in the IRS instructions for form W-9.
Part V: Contact Information
Please provide the contact information for an executive at your organization. This individual should be
the person who makes legal and financial decisions for your organization.
1
According to IRS Regulations, OSC must withhold 28% of all payments if a payee/vendor fails to provide OSC its certified TIN. The Substitute Form W-9
certifies a payee/vendor’s TIN.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome