Fillable Supplier App 12-2018 Pgs 3-4 UNIVERSITY OF WYOMING

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Supplier App 12-2018 Pgs 3-4 UNIVERSITY OF WYOMING

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3 | Revised 12/14/18
Procurement & Payment Services
Dept. 3605, 1000 E University Avenue
Laramie WY 82071
307-766-5233 Fax: 307-766-2800
procurement-card@uwyo.edu
Supplier Form/Substitute W-9
Instructions: If you are a U.S. citizen, resident alien or U.S. business, please provide all information as requested in the spaces provided. If you, the recipient, or
the beneficiary of the payment is not a U.S. citizen, resident alien or U.S. business please provide all information as requested, but DO NOT sign the
certification in Section B and contact the Tax Office at 307-766-2821 to complete the additional required tax forms.
General Terms & Conditions can be found on the following web site: http://www.uwyo.edu/procurement/
Payment Terms: Net 45
UW is a tax exempt organization.
Forms that are illegible or incomplete will not be processed.
Section A - All Suppliers Must Complete
General Information
Name (as shown on your income tax return): _______________________________________________________________________________________________
Business name/disregarded entity name, if different from above: ________________________________________________________________________________
Payments should be issued to: _____________________________________________________________________________________________________
Order Address: _______________________________________________ City:_______________________ State: ______Zip:____________
Order E-Mail Address: ____________________________________________________Order Fax #:_______________________________________
Bid Solicitation Address: _______________________________________________ City:_______________________ State: ______Zip:____________
Bid E-Mail Address: ____________________________________________________ Bid Fax #:________________________________________
Remittance Address: _______________________________________________ City:_______________________ State: ______Zip:____________
Electronic Payment Remittance Advice E-Mail Address: _______________________________________________________________________________________
Sales Contact: ________________________________________ Phone #:____________________Email_____________________________
Management Contact: ________________________________________ Phone #:____________________Email_____________________________
Toll Free Phone Number: ________________________________________ WWW Address: _______________________________________________
DUNS Number: ________________________________________
ALL COMPANIES PRODUCING PRODUCTS BEARING THE UNIVERSITY’S MARKS MUST RECEIVE PRIOR APPROVAL THROUGH THE UNIVERSITY’S LICENSING OFFICE
Statement of Employee Ownership Interest
Yes No Is any University of Wyoming employee an Officer, Director, Partner, or hold any paid position in this company?
Yes No Does the University of Wyoming provide employment for any party (or their spouse or minor child) that has a 5%
or greater ownership interest in this company?
If you have answered yes to either question please attach a list identifying these individuals and their relationship to your company
Section B – Substitute W-9: Request for Taxpayer Identification Number and Certification –
All Suppliers Must Complete.
Check Federal Tax Classification
Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/Estate
Limited Liability Company Enter the tax classification (C= Corporation, S= S Corporation, P=Partnership) ___
Government agency or organization that is tax-exempt under IRS guidelines
Foreign Individual Foreign Business Other___________________
Check as many as apply: Medical Service Provider Lawyer/Attorney Agent
Required: 1099 Address, if different______________________________________________________________________________________________________
Taxpayer Identification Number
Employer Identification Number (EIN) _ _ - _ _ _ _ _ _ _ -or- Social Security Number _ _ _ - _ _ - _ _ _ _
4 | Revised 12/14/18
Under penalties of perjury, I certify 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 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. citizen or other U.S. person.
Certification instructions. You must cross out item 2 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, item 2 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, you are not required to sign the certification, but you must provide your correct TIN.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Authorized Signature
I certify that the information supplied herein (including all pages attached) is correct and that neither the applicant nor any person (or concern) in any connection with
the applicant as a principal or officer, so far as is known, is now debarred or otherwise declared ineligible by the U.S. Government or by any Governmental agency of
the State of Wyoming from bidding or furnishing materials, supplies or services to the U.S. Government or Wyoming State Government or any agency thereof.
Signature______________________________________________________ Date___________________
Payee Information Return Instructions
1. If you or your business receive payments from the University of Wyoming, this form must be completed and signed before checks can be issued to you. Forms
that are illegible or incomplete will not be processed.
2. Forms for Payee Suppliers only should be mailed to the address above, faxed to 307-766-2800 or scanned and e-mailed to procurement-card@uwyo.edu.
3. If you require assistance in completing the form, please call 307-766-5296 or 307-766-5233.
4. All checks or electronic payments are issued by the UW Payment Services Office. Attached remittance advice (check stub) or e-mailed remittance advice
shows the supplier invoice number or description. Please ensure that whenever possible your billing system provides this information so that we can
better identify payments to you on the remittance advice.
INSTRUCTIONS:
1. Items 1-7 Section A and Section B must be completed on an initial application for the form to be processed. To revise an address, complete applicable item in
Section A and provide either the SSN or EIN in Section B.
2. Tax Residency: Indicate only one tax residency status. If you are not a resident of the USA for tax purposes, please specify your tax home. If you have questions
on tax residency, contact the Tax Compliance Accountant at 307-766-2821.
3. Sign and date the certification. Sole proprietors and individuals must sign for themselves. For other entities, an authorized person must sign the certification.
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Supplier App 12-2018 Pgs 3-4 UNIVERSITY OF WYOMING

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Completed 10 February 2020

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