Fillable Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form (US House of Representatives)

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Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form (US House of Representatives)

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SECTION I
UNITED STATES HOUSE OF REPRESENTATIVES INFORMATION
ADDRESS CAO OFFICE OF ACCOUNTING, 337 FORD HOUSE OFFICE BUILDING, WASHINGTON, DC 20515
53-6002523
TELEPHONE NUMBER (202) 226-2277
SECTION II PAYEE/COMPANY INFORMATION
CHECK APPROPRIATE BOX FOR FEDERAL TAX CLASSIFICATION (required)
Trust/Estate
Exempt
payee
TYPE OF TAX IDENTIFICATION NUMBER
CONTACT PERSON NAME
EMAIL
TELEPHONE NUMBER
FAX NUMBER
TELEPHONE NUMBER
FAX NUMBER
REMIT TO ADDRESS
SECTION III
FINANCIAL INSTITUTION INFORMATION
BANK NAME (Branch City, State)
TELEPHONE NUMBER
DEPOSITOR ACCOUNT TITLE
LOCKBOX NUMBER
CHECKING SAVINGS LOCKBOX
SECTION IV
SOCIO-ECONOMIC INFORMATION
Type of Business Large Business-No Socio-Economic Designations Minority SmBusiness Sm-Disadv/Minority Sm-Disadv Only SmMin Only
Sm-Disadvantaged Business Prog 8 (a) Firm HUBZone Program HUBZone Eligible
Emerging Small Business
Women-Owned Business
Other Preference Programs Buy Indian Directed to JWOD Non-Profit No Preference/Not Listed Small Business Set-Aside Very Small Business Set-Aside
Veteran Owned Status Non-Vet Owned SmBus Other Vet Owned SmBus Serv-Disabled Vet Other Bus Serv-Disabled Vet Owned SB Vet-Owned Other Bus
Size of Business: (A) 50 or less (B) 51-100 (C) 101-250 (D) 251-500 (E) 501-750 (F) 751-1,000 (G) Over 1,000 (M) 1 million or less
(N) 1.1-2 million (P) 2.1-3.5 million (R) 3.1-5 million (S) 5.1-10 million (T)10.1-17 million (Z)Over 17 million
SECTION V
CERTIFICATION OF DATA BY PAYEE/COMPANY
TITLE/POSITION
EIN
TELEPHONE NUMBER
SIGNATURE
NAME
EMAIL
NINE-DIGIT ROUTING TRANSIT NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___
TYPE OF ACCOUNT
DEPOSITOR ACCOUNT NUMBER
ACH COORDINATOR NAME
Internal Revenue Code 6109, 31 U.S.C. 3322, 31 CFR 210 and the 1996 Debt Collection Improvement Act require all entities that do business with the
United States Government to provide a Tax Identification Number (TIN) and Electronic Funds Transfer (EFT) information for payment. PL 93-579
protects your privacy and mandates that the information never be published or used for any other purpose than to pay you. Please complete all sections
below, sign and return via the email or fax number listed.
U.S. House of Representatives
Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form
C Corporation
Partnership
S Corporation
RETURN FORM TO:
AGENCY IDENTIFIER
AGENCY LOCATION CODE 4832
VendorEFT@mail.house.gov
FAX NUMBER:
(202) 225-6914
SOCIAL SECURITY NUMBER (or)
ENTER TAX IDENTIFICATION NUMBER
NAME (AS SHOWN ON YOUR INCOME TAX RETURN)
BUSINESS NAME/DISREGARDED ENTITY NAME or DBA, IF DIFFERENT THAN ABOVE
ADDRESS/CITY/STATE/ZIP
Individual/
Sole
Proprietor
Limited Liability Company Enter tax classification
(C=C corporation, S=S corporation, P= Partnership)
PURCHASE ORDER ADDRESS/CITY/STATE/ZIP
OTHER (Other entities. Enter your business name below as shown on required federal tax
documents “Name” line.
This name should match the name shown on the charter or other legal
document creating the entity.
You may enter any business, trade, or DBA name on the “Business
name/ disregarded entity name” line.)
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U.S. House of Representatives
Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form
Section I - Agency Information – Includes the name and address, agency identifier, agency location code and
telephone number for the House of Representatives.
Section II - Payee/Company Information – Print or type the name of the payee/company and address that will
receive payment, social security or taxpayer ID number, contact person name, telephone number and email of the
payee/company. Print or type the purchase order and remit to addresses if different from the payee/company
address. Check the appropriate boxes for federal tax classification.
Section III - Financial Institution Information – Print or type the name and address of the payee/company’s
financial institution who will receive the ACH payment, ACH coordinator name and telephone number, nine-digit
routing transit number, depositor (payee/company) account title and account number. Check the appropriate box
for type of account. Payee/Company may include a voided check with this form.
ACH Account Information Located on a Check or Deposit Ticket
FINANCIAL INSTITUTION NAME name of the financial institution to which the payments are to be directed
ROUTING TRANSIT NUMBER (RTN) financial institution's 9 digit routing transit number;
found on the bottom of a check or deposit ticket or from your Financial Institution
ACCOUNT TITLE employee's or vendor's name on the account
ACCOUNT NUMBER account number at the financial institution
Section IV - Socio-Economic Information – Check the boxes for each category, if applicable: type of business,
small disadvantaged business program, HUBZone program, emerging small business, women-owned business,
other preference programs, Veteran owned status and size of business. Detailed information related to Small
Business programs can be found at http://www.sba.gov/.
Section V - Certification of Data By Payee/Company – Print or type the name, title/position and phone number of
the Authorized official. The Authorized official must sign and date the form.
1. Routing Transit Number (RTN)
– nine digits located between
two symbols. This number
identifies the bank holding your
account and check processing
center.
2. Account number – this is your
complete account number.
Your account number can be
up to 17 digits. Please include
leading zeros.
3. ACH Routing Transit Number –
Automated Clearing House
routing number, use this
number for your Routing
Transit Number (RTN) if you
bank with SunTrust Bank.
4. Check number – This
information is not necessary -
do not provide
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Substitute W-9 and ACH VendorMiscellaneous Payment Enrollment Form (US House of Representatives)

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Completed 10 November 2021

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