Fillable SUBSTITUTE W-9 FORM Request for Taxpayer Identification Number (Information Technology Services)

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SUBSTITUTE W-9 FORM Request for Taxpayer Identification Number (Information Technology Services)

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NC Office of the
State Controller
(IRS Form W-9 will not be
accepted in lieu of this form)
*Denotes a Required Field
STATE OF NORTH CAROLINA
SUBSTITUTE W-9 FORM
Request for Taxpayer Identification Number
Please complete the “Modification to Existing Vendor Records” section below If there have been any changes to the following: Tax Identification Number (TIN),
Legal Name, Business Name, Remittance Address
Return to the NC State Agency from which you are requesting payment.
Section 1 – Taxpayer Identification
Section
2 -Certification
*1. Social Security Number (SSN),
OR
Employer Identification Number (EIN),
OR
Individual Taxpayer Identification Number (ITIN)
*2.
Please select the appropriate Taxpayer Identification Number (EIN, SSN,
or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer
Identification Number is being requested per U.S. Tax Law. Failure to
provide this information in a timely manner could prevent or delay
payment to you or require The State of NC to withhold 28% for backup
withholding tax.
*4. Legal Name (as shown on your income tax return):
3. Dunn & Bradstreet Universal Numbering System (DUNS) (see
instructions)
5. Business Name/DBA/Disregarded Entity Name, if different from
Legal Name:
Contact Information
*6. Legal Address
7. Remittance Address (Location specifically used for payment that is
different from Legal Address, if applicable)
*
Address Line 1:
Address Line 1:
Address Line 2:
Address Line 2:
*
City
*
State
*
Zip (9 digit)
City State Zip (9 digit)
*County
County
*12. Entity Type
*13. Entity
Classification
14. Exemptions (see
instructions)
Individual/Sole Proprietor/Single-member LLC C-Corporation S-Corporation
Partnership Trust/Estate Other___________________________
Limited liability company. Enter the tax classification (C=C corporation,
S=S corporation, P=Partnership) ________
Note: Check the appropriate box in the line above for the tax classification of the single-
member owner. Do not check LLC if the LLC is classified as a single-member LLC that is
disregarded from the owner unless the owner of the LLC is another LLC that is not
disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC
that is disregarded from the owner should check the appropriate box for the tax classification
of its owner.
Exempt payee code (if any):
Exemption from FATCA
reporting code (if any):
Under penalties of perjury, I certify that:
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
2. 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 because 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 later in general instructions), and
4. The FATCA code(s) entered on this form (if any) indicting that I am exempt from FATCA reporting is correct.
Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/
):
Printed Name:
*
Printed Title:
Authorized U.S.
*
Date:
Medical Services
Legal/Attorney
Services
NC Local Govt
Federal Govt
NC Stat
e Agency
Other Govt
Other (specify)
click to sign
signature
click to edit
NC Office of the
State Controller
*Denotes a Required Field
This form is to be
completed by the vendor.
STATE OF NORTH CAROLINA
SUBSTITUTE W-9 FORM
Modification to Existing Vendor Records
This form is to be completed by the vendor if one or more of the following have changed:
1. Change of remittance address.
2. Change of Social Security Number (SSN), or Employer Identification Number (EIN), or Individual Taxpayer
Identification Number (ITIN).
3. Change of Vendor Name.
Please complete the applicable sections below.
Section 1:
CHANGE FROM: Remittance Address
CHANGE TO: Remittance Address
Section 2:
* CHANGE FROM: SSN, or EIN, or ITIN
* CHANGE TO: SSN, or EIN, or ITIN
Section 3:
CHANGE FROM: Vendor Name
CHANGE TO: Vendor Name
*Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
*
County
*Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
*
County
*Legal Name:
*Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
*Printed Name: *Printed Title:
*Authorized U.S.
Signature:
* Date:
NOTE: If you would like to receive your payments electronically, please
complete the Vendor Electronic Payment Form
click to sign
signature
click to edit
NC Office of the State Controller Substitute W-9 Instructions Page 1
General Instructions
For General Instructions, please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/).
Specific Instructions
Section 1 -Taxpayer Identification
1. Taxpayer Identification Type. Check the type of identification number provided in box 2.
2. Taxpayer Identification Number (TIN). Enter taxpayer’s nine-digit Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer
Identification Number (ITIN) without dashes.
Note: If an LLC has one owner, the LLC's default tax status is "disregarded entity". If an LLC has two owners, the LLC's default tax status is "partnership". If an LLC has
elected to be taxed as a corporation, it must file IRS Form 2553 (S Corporation) or IRS Form 8832 (C Corporation).
3. Dunn and Bradstreet Universal Numbering System (DUNS). Vendors are requested to enter their DUNS number, if applicable.
4. Legal Name. Enter the legal name as registered with the IRS or Social Security Administration. In general, enter the name shown on your income tax return. Do
not enter a Disregarded Entity Name on this line.
5. Business Name. Business, Disregarded Entity, trade, or DBA ("doing business as") name.
Contact Information
6. Enter your Legal Address.
7. Enter your Remittance Address, if applicable. A Remittance Address is the location in which you or your entity receives business payments.
8. Enter the Contact Name.
9. Enter your Business Phone Number.
10. Enter your Fax Number, if applicable.
11. Enter your Email Address, if applicable.
For clarification on IRS Guidelines, see www.irs.gov
.
12. Entity Type. Select the appropriate entity type.
13. Entity Classification. Select the appropriate classification type.
Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and
Exemption from FATCA reporting code below.
14. Exempt payee code. 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. Corporations are not exempt from backup withholding for payments made in settlement of
payment card or third party network transactions.
Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.
The following codes identify payees that are exempt from backup withholding:
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
5 - A corporation
6 - A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States
7 - A futures commission merchant registered with the Commodity Futures Trading Commission
8 - A real estate investment trust
9 - An entity registered at all times during the tax year under the Investment Company Act of 1940
10- A common trust fund operated by a bank under section 584(a)
11 - A financial institution
12 - A middleman known in the investment community as a nominee or custodian
13 - A trust exempt from tax under section 664 or described in section 4947.
NC Office of the State Controller Substitute W-9 Instructions Page 2
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
If the payment is for…
THEN the payment is exempt for…
Interest and dividend payments
All exempt payees except for 7
Broker transactions
Exempt payees 1 through 4 and 6 through
11 and all C corporations. S corporations
must not enter an exempt payee code
because they are exempt only for sales of
noncovered securities acquired prior to
2012.
Barter exchange transactions and patronage
dividends
Exempt payees 1 through 4
Payments over $600 required to be reported and
direct sales over $5,000¹
Generally, exempt payees 1 through 5²
Payments made in settlement of payment card
or third party network transactions
Exempt payees 1 through 4
¹ See Form 1099-MISC, Miscellaneous Income, and its instructions.
² However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting
this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account
you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to
these requirements.
A - An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
B - The United States or any of its agencies or instrumentalities
C - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities
D - A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472- 1(c)(1)(i)
E - A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i)
F - A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as
such under the laws of the United States or any state
G - A real estate investment trust
H - A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I - A common trust fund as defined in section 584(a)
J - A bank as defined in section 581
K - A broker
L - A trust exempt from tax under section 664 or described in section 4947(a)(1)
M - A tax exempt trust under a section 403(b) plan or section 457(g) plan
Section 2 - Certification
To establish to the paying agency that your TIN is correct, you are not subject to backup withholding, or you are a U.S. person, or resident alien, sign the certification
on NC Substitute Form W-9. You are being requested to sign by the State of North Carolina.
For additional information please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/
).
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SUBSTITUTE W-9 FORM Request for Taxpayer Identification Number (Information Technology Services)

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Completed 14 August 2020

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