Business Services
Montana State University Billings
1500 University Drive
Billings, Montana 59101-0245
Phone: (406) 657-2301
Fax: (406) 657-2051
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER - SUBSTITUTE W-9 FORM
(Use this form in place of IRS W-9 Form)
U.S. Resident - Individual / Sole Proprietor (Form 1099 reportable) (Complete ONE box only)
Legal Name (as entered with IRS): Trade Name (DBA):
Remit to Address (where the payment should be mailed)
PO Box or Number and Street
City, State, Zip+4
Phone Number: Email Address:
Entity Designation (check only one type)
Individual Sole Proprietorship C Corporation S Corporation Partnership LLC
(Check All That Apply)
Do you provide medical services? Exempt from Tax (under 501 A thru E)?
Minority owned business?
Are you providing legal services? Are you a Government Entity? Women owned business?
Tax Payer Identification Number (TIN) (Provide Only One)
Social Security Number:
- -
Employer Identification Number :
-
Certification: Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, 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 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.
3. I am a US Person (including a US resident alien).
Signature:
Printed Name:
Title:
Date: Phone:
MSUB Substitute W-9 Form - Revised 11/2013
