Southeastern Louisiana University
Division of Administration and Finance - Controller's Office
Request for Taxpayer Identification and Certification
(Substitute for IRS Form W-9)
Legal Name
Business Name (if differenct from above)
Check Appropriate Box
Individual/Sole Proprietor Corporation
Limited Liability CompanyPartnership
Association/Estate/Trust
Tax-Exempt Organization (501C)
Government
Other
Address (Number, street, and apt or suite no.)
City, State and Zip Code
Part I - Taxpayer Identification Number (TIN)
Social Security Number (SSN) Employer Identification Number (EIN) Individual Taxpayer Identification Number (ITIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given above to avoid backup withholding. For Individuals, this is your Social Security
Number (SSN) or Individual Taxpayer Identification Number (ITIN). For other entities, it is your Employer Identification Number (EIN).
Part II - Exemption
If exempt from 1099 reporting, check the appropriate box for qualifying exemption reason below:
Corporation, expect there is no exception for medical and healthcare payments or payments for legal services
Tax exempt Charity under 501(a) or IRA
The United States or any or its agencies or instrumentalities
A state, District of Columbia, a possession of the United States, or any of their political subdivisions
A foreign government or any of its political subdivisions
Part III - Supplemental Information
Please check appropriate Provider type of services:
Rents or royalty payments; prizes and awards that are not services, such as, winning on TV or radio shows
Payments to crew members by owners or operators of fishing boats, including payments of proceeds from sale of catch
Payments to physicians, physicians' corporations, or other supplier of health and medical services. Issued mainly by medical assistance programs or health and accident insurance plans
Payments for services performed for a trade or business by people not treated as its employees. Examples: Fees to sucontractors or directors and golden parachute payments
Crop Insurance proceeds
Gross proceeds paid to attorneys
Payments for accounting and/or CPA services
Part IV - Certification
Under the penalties of perjury, I certify that:
(1) The number shown on this form, is my correct taxpayer identification number (or I am writing 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 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 US person, including a US resident alien.
The Internal Revenue Service does not require your consent to any provision of this document other than certifications required to avoid backup withholding.
Signature
Name of Individual completing this Form
Date
Telephone Number E-mail Address
Rev. 2/29/2012
Please Print and Fax Electronically Completed Form to (985) 549-3802.
Handwritten forms will not be accepted.
