II. Contact Names
Other W-9 forms and substitutions are not accepted.
Grant Application Contact:
Email
Accounts Payable Contact:
Email
Remit Address
City
Signature
I
certify by completion of this form 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 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. person (including a U.S. resident alien), and 4. By providing bank and account information and signing this form, I/we
authorize Lake County Government and the financial institution identified to deposit all payments due automatically, in accordance with agreed upon
payment terms. This authority will remain in effect until I/we notify Lake County in writing of its cancellation. The Internal Revenue Service does not
require your consent to any provision of this document other than the certifications required to avoid backup withholding.
I. Business Name
Name
Address
Telephone
Web address or URL
Substitute Form W-9 / Supplier Registration
*This is a fillable PDF form. You can enter the appropriate information, save
the changes and download this document to your computer.
City
State
Zip Code
Electronic Remitance email
Taxpayer ID (EIN or SSN)
Telephone
Telephone
Fax
Fax
III. Type of Organization
State
Zip Code
Office Use Only
Department
Employee
Finance
Date
New
Existing
This M/W/DBE information requested below is voluntary and gathered for demographic reporting only.
VI. M/W/DBE:
Minority/Woman/Disadvantaged Business Enterprise:
No
Approved
Date
Yes
Date
click to sign
signature
click to edit
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