Substitute Request for Taxpayer W-9
Identification Number and Certification Substitute Form
(Rev. 04APR19)
Page 1 of 2 SIGNATURE REQUIRED on Page 2
Email completed form to:
Name (as shown on your income tax return). Name is required on this line; do not leave this line blank:
Business name/disregarded entity name, if different from above:
Check appropriate box for federal tax classification; check only one of the following seven boxes:
Individual/sole proprietor or single-member LLC
C Corporation
S Corporation
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.
Other (specify)
Exemptions (codes apply only to certain entities, not individuals):
Exempt payee only (if any)
Exemption from FATCA reporting code (if any)
Address (number, street, and apt. or suite no.):
City, State, and ZIP code:
Tax Identification Number (TIN)
The TIN provided must match the name given on “Name line 1 to avoid backup withholding. For individuals, this is
generally your social security number (SSN). For entities, it is your employer identification number (EIN).
Social security number - -
Or Employer identification number -
Sales contact person:
Accounts Receivable contact person:
Address (number, street, and apt. or suite no.):
Address (number, street, and apt. or suite no.):
City, state, and ZIP code:
City, state, and ZIP code:
Email (Contracts/Purchase Orders will be emailed):
Website URL:
Page 2 of 2
Have you previously done business with Portland Community College: ____Yes ____No ____Unknown
Have you previously been or are you currently an employee of Portland Community College: ___Yes ___No
If Yes, enter employment end date or current:______________
Please indicate Inclusion and Diversity certifications:
U.S. Small Business Administration
Oregon COBID
Disadvantaged Business Enterprise (DBE)
Disadvantage Business Enterprise
Emerging Small Business (ESB)
Hub Zone
Minority Business Enterprise (MBE)
Minority Owned
Service Disabled Veteran Business Enterprise (SDVBE)
Service Disable Veteran Owned
Women Business Enterprise (WBE)
Veteran Owned
Women Owned
Other Certification:
Cert Number or ID: Cert Expiration Date:__________________
Under penalty of perjury, I certify that:
a. 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
b. I am not subject to backup withholding because: (i) I am exempt from backup withholding, or (ii) 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 (iii) the IRS has notified me that I am no longer subject to backup
withholding; and
c. I am a U.S. citizen or other U.S. person who is legally allowed to work in the U.S.; and
d. I am authorized to conduct business within the State of Oregon; and
e. The FATCA codes(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions: You must cross out item b. above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real
estate transactions, “Business name does not apply. For mortgage interest paid, acquisition or abandonment of
secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally,
payments other than interest and dividends.
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
Signature of U.S. Person Date: __________