Form W-9
(Rev.
November 2017)
Department
of
the
Treasury
Internal Revenue
Service
Request for
Taxpayer
Identification
Number
and
Certification
Go to www.irs.gov/FormW9 for
instructions
and the latest
information.
Give Form to the
requester. Do not
send to the IRS.
Print
or type.
See
Specific
Instructions
on page 3.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
C Corporation S Corporation Partnership Trust/estate
single-member LLC
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
(see
instructions)
4 Exemptions (codes apply only
to
certain entities, not individuals; see
instructions on page 3):
Exempt
payee
code (if any)
Exemption from
FATCA
reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
7 List account
number(s)
here (optional)
Part
I
Taxpayer Identification Number (TIN)
Social security number
Employer identification number
Part
II
Certification
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number
(SSN).
However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number
(EIN).
If you do not have a number, see How to get a
TIN, later.
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
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 (defined below); and
4. The
FATCA
code(s) entered on this form (if any) indicating that I am exempt from
FATCA
reporting is correct.
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. See
the
instructions
for
Part
II, later.
Sign
Here
Signature of
U.S. person
Date
General Instructions
Section references are to the Internal
Revenue
Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number
(TIN)
which may be your social security number
(SSN),
individual taxpayer identification number
(ITIN),
adoption
taxpayer identification number
(ATIN),
or employer identification number
(EIN),
to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
Form 1099-INT (interest earned or paid)
Form 1099-DIV (dividends, including those from stocks or mutual
funds)
Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
Form 1099-S (proceeds from real estate transactions)
Form 1099-K (merchant card and third party network transactions)
Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
Form 1099-C (canceled debt)
Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien),
to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
See additional instructions on Page 4 of this document
Fax:
Address (Street Name/No.):
Telephone:
Fax:
No
Will you be selling supplies, goods, or merchandise to USG?
Yes
City:
Website URL:
State:
Zip Code:
Email:
Instructions:
1.Complete pages 1-2 of this form electronically. If you prefer to complete the form by hand, please print legibly in black ink and clearly
distinguish numbers.
Note: Omissions of requested information on this form may result in delayed registration and/or payment.
2. Print and sign form.
3. Send the form to the University System of Georgia Shared Services Center using one of the following methods:
-Mail to the USG Shared Services Center (see address above)
-Fax to (478)240-6414
-Hand deliver to the institution for upload to the Shared Services Center secure FTP server
Email Submissions are not accepted.
USG Shared Services Center
1005 George J. Lyons Pkwy
Sandersville, GA 31082
Fax: 478-240-6414
Supplier Information Form and W-9
Do Not Send This Form to IRS
Legal Name (Name Used On Tax Filing):
Add
Change-Existing Supplier ID #
Contact Person at Requesting USG Institution:
Purchase Order Address:
Required if different from address provided on W-9.
Address (Street Name/No.):
City:
Telephone:
Website URL:
State:
Contact Name:
Zip Code:
Email:
Required if different from address provided on W-9.
Is this for New Supplier Addition or Change of
Existing Information?
Supplier Business Type Information
Are you primarily a supplier of services?
Yes
No
E-Verify Identification #
Payment (Remit) Address:
Name of Requesting USG Institution:
Same as address provided on W-9
Same as address provided on W-9
Non-US tax resident individuals and entities and USG employees and students cannot use
this process for vendor registration.
Foreign vendors must complete the IRS W-8BEN form and the Foreign Vendor Profile Form.
http://www.irs.gov/pub/irs-pdf/fw8ben.pdf
Employees and students should contact the HR office at their institution.
Do you expect to receive payment for any of the following from USG? Select all that apply.
Services performed as a nonemployee of USG (independent contractor)
Provision of medical or health care services
Provision of legal services
Royalties (intangible property such as patents and copyrights, mineral right usage)
Rents (real estate or machinery)
For questions about this form, please call (478)240-6500 or email vendor_registration@ssc.usg.edu.
Have you registered with the federal E-Verify Program?
No
Yes
Awards/Prizes
Fellowship, Training Stipend, Research Participant
Honorarium
Short Course Instructor Professional Education
Registration
Repairs/Maintenance
Expense reimbursement as a non-employee
Based on the State of Georgia classification in the link below, would your organization be
considered a small business?
http://www.georgia.org/business-resources/small-business-resources/Pages/small-business-tools.aspx
Yes
No
USG Shared Services Center
1005 George J. Lyons Pkwy
Sandersville, GA 31082
Fax: 478-240-6414
Supplier Information Form and W-9
Non-US tax resident individuals and entities and USG employees and students cannot use
this process for vendor registration.
Foreign vendors must complete the IRS W-8BEN form and the Foreign Vendor Profile
Form.
http://www.irs.gov/pub/irs-pdf/fw8ben.pdf
Employees and students should contact the HR office at their institution.
Do Not Send This Form to IRS
Supplier Business Type Information Continued
Based on the State of Georgia classification in the link below, would your organization be considered a minority business?
http://www.georgia.org/business-resources/small-business-resources/women-minority-business/Pages/default.aspx
Yes
No
If yes, please select your minority category to the right.
Minority Categories
African American
Asian American
Hispanic/Latino
Native American
Pacific Islander
According
to
the
Department
of
Administrative
Services
(DOAS)
classification
in the
link
below,
are
you
a
Georgia
resident
business?
http://doas.ga.gov/state-purchasing/FAQ#9
Yes
No
Method of Payment
Check
ACH - Electronic Funds Transfer
Start
Change
Stop
Name Change Only
Banking Information
Account Type
ACH Electronic Funds Transfer Action Required
(Select only One)
(Select only One)
Individual Checking
Individual Savings
Corporation
(Required for ACH)
Clearly distinguish numbers for example, use Ø for zero and 7 for seven.
Bank Name:
Routing Number:
Account Number:
Re-enter Account Number:
Authorized Signature
(Required for ACH)
ACH Contact Name:
Re-enter Account Number:
Email for ACH Confirmation:
(Required)
Signature of U.S. Individual:
Date:
THIS FORM MUST BE SIGNED AND DATED BY PAYEE FOR ACH
For ACH only, the signature above also signifies acceptance of the terms and conditions in the agreement below
AGREEMENT
- I hereby authorize USG or any affiliated institution to electronically deposit all
invoice payments to my account in the financial institution listed above. In the
event that a USG Institution notifies the financial institution that funds have been
deposited to my account in error, I hereby authorize and direct the financial
institution to return said funds to the institution as soon as possible. In the event
such funds have been drawn from that account so that return of those funds by
the financial institution to the USG institution is not possible, I agree to
immediately repay any erroneous deposits to the institution. I further agree that if I
do not immediately repay an erroneous deposit, I will be liable for all costs of
collection, including reasonable attorney’s fees incurred by the USG institution in
the collection of such erroneous deposit, together with the maximum interest
permitted by law. Furthermore, in the event of failure to repay any amounts I owe
to the institution, I hereby authorize the institution to recover such amounts by
deducting them from any future payments until the amounts owed are recovered
in full. I understand that this authorization is to remain in effect until USG Shared
Services Center has received written notification from me of its termination in
such time and manner as to afford USG SSC, and the financial institution named
above, a reasonable opportunity to act upon it, provided, however, that after
termination, I shall remain liable for any amounts owed to the USG institution. I
certify that I am authorized to sign on behalf of my company.
ACH - Electronic Fund Transfer Instructions
Use this form to start, change, or stop electronic payments from
a USG institution. Employees should visit OneUSG Connect
web portal to change payroll preferences.
Name:
Ensure the name on the Payment authorization matches the name
listed on the Form W-9. Electronic payments will not be processed if
the names do not match.
Action Required:
1. Select Start to set up electronic payments for the first time.
2. Select Change to update banking information for electronic
payments. Electronic payments will be stopped once a change
request is received, and payments will be issued via check until
the new banking information is verified and updated.
3. Select Stop to terminate electronic payments and revert to
check.
4. Select Name Change Only to update the name while
keeping the same banking information.
Note: An updated W-9 is also required to reflect a name
change.
Banking Information:
Routing number is the nine-digit number
that identifies your financial institution. It is
found in the bottom left-hand corner of a
check.
Include all leading zeroes in the account
number.
Contact your financial institution for
help with account numbers.
Note:
For first time ACH payments, pre-
notification is required and payment will
begin within 10 days after a pre-note is
initiated.
Note: Electronic payments will only be
made to U.S. banks.
For questions about this form, please call (478)240-6500 or email vendor_registration@ssc.usg.edu.
“Remaining fields must be completed for
electronic payment.”
click to sign
signature
click to edit
Form W-9 (Rev.
11-2017)
By signing
the filled-out
form,
you:
1. Certify
that the
TIN you are
giving
is correct (or you are
waiting for a
number
to
be
issued),
2. Certify
that
you are
not
subject
to
backup
withholding, or
3. Claim exemption
from
backup
withholding if
you are a U.S.
exempt
payee.
If
applicable, you are also certifying
that
as a U.S.
person,
your
allocable
share
of
any partnership income
from
a U.S.
trade
or
business is
not
subject
to the withholding
tax
on
foreign partners' share
of effectively
connected income,
and
4. Certify
that
FATCA code(s)
entered
on
this
form (if
any)
indicating that
you are exempt
from the
FATCA
reporting,
is correct. See What is FATCA
reporting, later,
for further information.
Note:
If
you are a U.S.
person and a requester gives you a
form other than
Form W-9
to
request your TIN, you must use
the
requester’s
form if it is
substantially similar
to
this Form
W-9.
Definition
of a
U.S. person.
For federal tax purposes, you are considered
a
U.S.
person
if
you
are:
An
individual who
is a U.S.
citizen
or
U.S.
resident
alien;
A partnership, corporation, company,
or
association created
or
organized
in
the
United States
or
under
the
laws
of the
United
States;
An estate (other
than
a foreign estate);
or
A domestic
trust
(as
defined
in
Regulations section
301.7701-7).
Special rules for partnerships.
Partnerships
that
conduct a trade
or business
in the
United States are generally required
to
pay a
withholding
tax
under
section 1446
on
any foreign partners’ share
of
effectively connected
taxable
income
from
such business. Further,
in
certain cases where a Form W-9
has
not
been received,
the
rules under section 1446 require a partnership
to
presume
that
a partner is a foreign person, and pay
the
section
1446
withholding
tax. Therefore,
if
you are a U.S.
person
that
is a partner
in a
partnership conducting a trade
or
business
in the
United States, provide
Form
W-9
to the
partnership
to
establish your
U.S.
status and avoid section
1446
withholding on
your share
of
partnership
income.
In the
cases below,
the following
person must give Form W-9
to the
partnership
for
purposes
of
establishing
its
U.S. status and
avoiding
withholding on its
allocable share
of net
income
from the partnership
conducting a trade
or
business
in the
United
States.
In the
case
of
a disregarded
entity with
a U.S.
owner,
the
U.S.
owner
of the
disregarded
entity
and
not the entity;
In the
case
of
a grantor
trust with
a U.S.
grantor
or other
U.S.
owner,
generally,
the
U.S.
grantor
or other
U.S.
owner
of the
grantor
trust
and
not the
trust;
and
In the
case
of
a U.S.
trust
(other
than
a grantor trust),
the
U.S.
trust (other
than
a grantor trust) and
not the
beneficiaries
of the trust.
Foreign person.
If
you are a foreign person
or the
U.S.
branch
of
a
foreign
bank
that
has elected
to
be treated
as a U.S.
person,
do not
use Form
W-9.
Instead, use
the
appropriate Form W-8
or
Form 8233 (see Pub.
515,
Withholding
of
Tax
on
Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes
a
resident alien.
Generally,
only a
nonresident alien
individual
may use
the
terms
of
a tax treaty
to
reduce
or
eliminate
U.S. tax
on
certain types
of
income. However, most tax
treaties
contain a provision
known
as a saving clause.” Exceptions specified
in the
saving clause may
permit
an exemption
from
tax
to
continue
for
certain
types
of
income even after
the
payee has otherwise become
a U.S.
resident alien
for
tax
purposes.
If
you are a U.S.
resident alien
who
is relying
on
an exception contained
in
the
saving clause
of
a tax treaty
to
claim an exemption
from
U.S. tax
on
certain types
of
income, you must attach a statement
to
Form W-9
that
specifies
the following
five
items.
1. The treaty country. Generally, this must be
the
same treaty under
which
you claimed exemption
from
tax as a
nonresident
alien.
2. The treaty article addressing
the income.
3. The article number (or location)
in the
tax treaty
that
contains
the saving
clause and
its exceptions.
4. The
type
and
amount of
income
that
qualifies
for the
exemption
from
tax.
5. Sufficient facts
to
justify
the
exemption
from
tax under
the
terms
of the
treaty
article.
Example.
Article 20
of the
U.S.-China income tax treaty allows an
exemption
from
tax
for
scholarship income received
by
a Chinese student
temporarily
present
in the
United States. Under
U.S.
law, this student
will
become
a
resident alien
for
tax purposes
if
his
or
her stay
in the
United States exceeds
5
calendar years. However, paragraph 2
of the first
Protocol
to the U.S.-China
treaty (dated
April
30, 1984) allows
the
provisions
of
Article 20
to
continue
to
apply even after
the
Chinese student becomes a resident alien
of the United
States. A Chinese student
who
qualifies
for
this exception (under paragraph
2
of the first
protocol) and is relying
on
this exception
to
claim an
exemption
from
tax
on
his
or
her scholarship
or
fellowship income
would
attach
to Form
W-9 a statement
that
includes
the
information described above
to
support
that
exemption.
If
you are a nonresident alien
or
a foreign entity, give
the
requester
the
appropriate completed Form W-8
or
Form
8233.
Backup
Withholding
What is backup withholding?
Persons making certain payments
to
you
must
under certain conditions
withhold
and pay
to the
IRS 28%
of
such
payments.
This is called “backup
withholding.”
Payments
that
may be subject
to backup
withholding
include interest, tax-exempt interest, dividends, broker
and
barter exchange transactions, rents, royalties, nonemployee pay,
payments
made
in
settlement
of
payment card and
third
party
network transactions,
and certain payments
from
fishing
boat
operators. Real estate
transactions
are
not
subject
to
backup
withholding.
You
will not
be subject
to
backup
withholding on
payments you receive
if
you give
the
requester your correct
TIN, make
the
proper certifications,
and
report
all your taxable interest and dividends
on
your tax
return.
Payments you receive
will
be subject
to
backup withholding
if:
1. You
do not
furnish your TIN
to the requester,
2. You
do not
certify your TIN when required (see
the
instructions
for
Part
II
for details),
3. The IRS tells
the
requester
that
you furnished an incorrect
TIN,
4. The IRS tells you
that
you are subject
to
backup
withholding
because
you
did not report
all your interest and dividends
on
your tax
return (for
reportable interest and dividends only),
or
5. You
do not
certify
to the
requester
that
you are
not
subject
to backup
withholding
under 4 above (for reportable interest and
dividend accounts
opened after 1983
only).
Certain payees and payments are exempt
from
backup
withholding. See
Exempt payee code, later, and
the
separate Instructions
for the
Requester
of
Form W-9
for
more
information.
Also see Special rules for partnerships,
earlier.
What is FATCA
Reporting?
The Foreign Account Tax Compliance Act
(FATCA) requires a
participating
foreign financial
institution to report
all United States account holders
that
are specified United States persons. Certain payees are exempt
from
FATCA
reporting.
See Exemption from
FATCA
reporting code, later, and
the Instructions
for the
Requester
of
Form W-9
for
more
information.
Updating Your
Information
You must provide updated information
to
any person
to whom
you
claimed
to
be an exempt payee
if
you are
no
longer an exempt payee and
anticipate
receiving reportable payments
in the future from
this person. For
example,
you may need
to
provide updated information
if
you are a C
corporation
that
elects
to
be an S
corporation,
or if
you
no
longer are tax exempt.
In addition,
you must furnish a new Form W-9
if the
name
or
TIN changes
for the account;
for
example,
if the
grantor
of
a grantor
trust dies.
Penalties
Failure
to
furnish TIN.
If
you
fail to
furnish your correct TIN
to
a
requester,
you are subject
to
a penalty
of
$50
for
each such failure unless your failure
is
due
to
reasonable cause and
not to willful neglect.
Civil penalty for false information
with
respect
to
withholding.
If you
make a false statement
with no
reasonable basis
that
results
in no backup
withholding,
you are subject
to
a $500
penalty.
Form W-9 (Rev.
11-2017)
Criminal penalty for falsifying information.
Willfully falsifying
certifications
or
affirmations may subject you
to
criminal penalties
including
fines
and/or
imprisonment.
Misuse
of
TINs.
If the
requester discloses
or
uses TINs
in violation of federal
law,
the
requester may be subject
to civil
and criminal
penalties.
Specific
Instructions
Line
1
You must enter one
of the following on
this line;
do
not
leave this
line blank.
The name should match
the
name
on
your tax
return.
If
this Form W-9 is
for
a
joint
account (other
than
an account maintained
by
a foreign financial
institution
(FFI)),
list
first, and
then
circle,
the
name
of the
person
or entity
whose number you entered
in
Part
I of
Form W-9.
If
you
are
providing
Form W-9
to
an FFI
to
document a
joint
account, each holder
of the
account
that
is a U.S.
person must provide a Form
W-9.
a.
Individual.
Generally, enter
the
name shown
on
your tax return.
If you
have changed your last name
without informing the
Social
Security
Administration
(SSA)
of the
name change, enter your
first
name,
the
last
name
as shown
on
your social security card, and your new last
name.
Note: ITIN applicant:
Enter your
individual
name as
it
was entered
on your
Form W-7 application,
line
1a. This should also be
the
same as
the
name
you
entered
on the
Form 1040/1040A/1040EZ you
filed with
your
application.
b.
Sole proprietor or single-member
LLC.
Enter your
individual
name as
shown
on
your 1040/1040A/1040EZ
on line
1. You may enter your
business,
trade,
or “doing
business as” (DBA) name
on line 2.
c.
Partnership,
LLC
that
is
not a
single-member
LLC, C
corporation, or S
corporation.
Enter
the
entity's name as shown
on the
entity's tax
return on
line
1 and any business, trade,
or
DBA name
on line 2.
d.
Other entities.
Enter your name as shown
on
required
U.S.
federal
tax
documents
on
line 1. 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
line
2.
e.
Disregarded entity.
For
U.S.
federal tax purposes, an
entity that is
disregarded
as an
entity
separate
from its
owner is treated as a
“disregarded
entity.”
See
Regulations section 301.7701-2(c)(2)(iii). Enter
the
owner's
name
on line
1. The name
of the entity
entered
on line
1 should never be
a
disregarded entity. The name
on line
1 should be
the
name shown
on the
income tax
return on
which
the
income should be reported. For example,
if a
foreign
LLC
that
is treated as a
disregarded
entity for
U.S.
federal tax
purposes
has a single owner
that
is a U.S.
person,
the
U.S.
owner's name is required
to
be
provided
on line
1.
If the
direct owner
of the entity
is also a
disregarded
entity,
enter
the first
owner
that
is
not
disregarded
for
federal tax
purposes.
Enter
the
disregarded entity's name
on line
2, “Business
name/disregarded entity
name.”
If the
owner
of the
disregarded
entity
is a foreign person,
the
owner must complete an appropriate Form W-8 instead
of
a Form
W-9.
This
is
the
case even
if the
foreign person has a
U.S.
TIN.
Line
2
If
you have a business name, trade name, DBA name,
or
disregarded
entity
name, you may enter
it on line 2.
Line
3
Check
the
appropriate
box on line
3
for the
U.S.
federal tax classification
of
the
person whose name is entered
on line
1. Check
only
one
box on line 3.
IF
the
entity/person on line
1 is
a(n)
. . .
THEN check
the
box for
. . .
Corporation
Corporation
Individual
Sole
proprietorship,
or
Single-member
limited liability
company
(LLC)
owned
by an
individual
and disregarded
for
U.S.
federal tax
purposes.
Individual/sole
proprietor or single-
member LLC
LLC
treated as a
partnership
for
U.S.
federal tax
purposes,
LLC
that
has
filed
Form 8832
or 2553
to
be taxed as a
corporation,
or
LLC
that
is disregarded
as an
entity
separate
from its
owner
but the
owner is another
LLC
that
is
not
disregarded
for
U.S.
federal
tax
purposes.
Limited
liability
company and
enter
the
appropriate tax
classification.
(P= Partnership; C=
C
corporation;
or
S= S
corporation)
Partnership
Partnership
Trust/estate
Trust/estate
Line
4, Exemptions
If
you are exempt
from
backup
withholding and/or
FATCA
reporting, enter
in
the
appropriate
space
on line
4 any code(s)
that
may apply
to you.
Exempt payee
code.
Generally, individuals (including sole proprietors) are
not
exempt
from
backup
withholding.
Except as
provided below, corporations are exempt
from backup
withholding for
certain payments,
including
interest and
dividends.
Corporations are
not
exempt
from
backup
withholding for
payments
made
in
settlement
of
payment card
or third
party
network transactions.
Corporations are
not
exempt
from
backup
withholding with
respect
to
attorneys’ fees
or
gross proceeds paid
to
attorneys, and corporations
that
provide medical
or
health care services are
not
exempt
with
respect
to
payments reportable
on
Form
1099-MISC.
The
following
codes
identify
payees
that
are exempt
from backup
withholding.
Enter
the
appropriate code
in the
space
in line 4.
1An organization exempt
from
tax under section 501(a), any
IRA,
or a
custodial account under section 403(b)(7)
if the
account satisfies
the
requirements
of
section
401(f)(2)
2The United States
or
any
of its
agencies
or instrumentalities
3A state,
the
District
of
Columbia,
a U.S.
commonwealth
or
possession,
or
any
of their political
subdivisions
or instrumentalities
4A foreign government
or
any
of its political
subdivisions, agencies,
or
instrumentalities
5A
corporation
6A dealer
in
securities
or
commodities required
to
register
in the United
States,
the
District
of
Columbia,
or
a U.S.
commonwealth
or possession
7A futures commission merchant registered
with the
Commodity
Futures
Trading
Commission
8A real estate investment
trust
9An
entity
registered
at
all times
during the
tax year under
the
Investment Company Act
of 1940
10A common
trust fund
operated
by
a bank under section
584(a)
11A financial
institution
12A middleman
known in the
investment community
as a
nominee
or
custodian
13A
trust
exempt
from
tax under section 664
or
described
in
section
4947
Form W-9 (Rev.
11-2017)
The
following
chart shows types
of
payments
that
may be exempt
from
backup
withholding.
The chart applies
to the
exempt payees listed above,
1
through 13.
IF
the
payment
is for
. . .
THEN
the
payment
is exempt for
. . .
Interest and
dividend payments
All
exempt payees
except
for 7
Broker
transactions
Exempt payees 1
through
4 and
6
through
11 and all C
corporations.
S
corporations must
not
enter
an
exempt payee code because
they are
exempt
only for
sales
of noncovered
securities acquired
prior to 2012.
Barter exchange transactions
and
patronage
dividends
Exempt payees 1
through 4
Payments over $600 required
to be
reported and direct
sales over
$5,000
1
Generally, exempt
payees
1
through 5
2
Payments made
in
settlement
of
payment card
or third
party
network
transactions
Exempt payees 1
through 4
1
See
Form 1099-MISC, Miscellaneous Income, and
its instructions.
2
However,
the following
payments made
to
a corporation
and
reportable
on
Form 1099-MISC are
not
exempt
from backup
withholding:
medical and health care payments, attorneys’ fees,
gross
proceeds paid
to
an attorney reportable under section 6045(f),
and
payments
for
services paid
by
a federal executive
agency.
Exemption from FATCA
reporting code.
The
following
codes
identify
payees
that
are exempt
from reporting
under FATCA. These codes apply
to
persons
submitting
this
form for
accounts maintained outside
of the United
States
by
certain foreign financial institutions. Therefore,
if
you are
only
submitting
this
form for
an account you
hold in the
United States, you
may
leave this
field
blank. Consult
with the
person requesting this
form if
you
are
uncertain
if the
financial
institution
is subject
to
these requirements.
A
requester may indicate
that
a code is
not
required
by providing
you
with a
Form W-9
with “Not
Applicable (or any similar indication)
written or printed
on the line for
a FATCA
exemption
code.
AAn organization exempt
from
tax under section 501(a)
or
any
individual
retirement plan
as defined
in
section
7701(a)(37)
BThe United States
or
any
of its
agencies
or instrumentalities
CA state,
the
District
of
Columbia,
a U.S.
commonwealth
or
possession,
or
any
of their political
subdivisions
or instrumentalities
DA corporation
the
stock
of
which is regularly traded
on
one
or more
established securities markets,
as described
in
Regulations section 1.1472-1(c)
(1)(i)
EA
corporation
that
is a member
of the
same expanded affiliated
group
as a
corporation described
in
Regulations section
1.1472-1(c)(1)(i)
FA dealer
in
securities, commodities,
or
derivative financial
instruments
(including
notional
principal contracts, futures, forwards, and options)
that is
registered
as such under
the
laws
of the
United States
or
any
state
GA real estate investment
trust
HA regulated investment company
as defined
in
section 851
or
an
entity
registered
at
all times
during the
tax year under
the
Investment Company
Act
of 1940
IA common
trust fund
as defined
in
section 584(a)
JA bank as defined
in
section
581
KA
broker
LA
trust
exempt
from
tax under section 664
or
described
in section
4947(a)(1)
MA tax exempt
trust
under a section 403(b) plan
or
section 457(g)
plan
Note:
You may wish
to
consult
with the
financial
institution
requesting
this
form to
determine whether
the
FATCA code
and/or
exempt payee
code
should be
completed.
Line
5
Enter your address (number, street, and apartment
or
suite number). This
is
where
the
requester
of
this Form W-9
will
mail your information returns.
If this
address differs
from the
one
the
requester already has
on
file,
write
NEW
at
the top. If
a new address is provided, there is
still
a chance
the old
address
will
be used
until the
payor changes your address
in their records.
Line
6
Enter your city, state, and ZIP
code.
Part
I.
Taxpayer Identification Number
(TIN)
Enter your TIN
in the
appropriate box.
If
you are a resident alien and you
do
not
have and are
not
eligible
to get
an SSN, your TIN is your
IRS
individual
taxpayer identification number
(ITIN). Enter
it in the
social security
number
box.
If
you
do not
have an ITIN, see How
to
get a TIN
below.
If
you are a sole
proprietor
and you have an EIN, you may enter either
your
SSN
or
EIN.
If
you are a single-member
LLC
that
is disregarded
as an
entity separate
from its
owner, enter
the
owner’s
SSN (or EIN,
if the
owner has one). Do
not
enter
the
disregarded entity’s
EIN.
If the
LLC is classified as a
corporation
or
partnership, enter
the
entity’s EIN.
Note:
See What Name and Number To Give the Requester, later,
for further
clarification
of
name and TIN
combinations.
How
to get a
TIN.
If
you
do not
have a TIN, apply
for
one immediately.
To
apply
for
an SSN,
get
Form SS-5,
Application
for
a Social Security Card,
from
your local SSA
office
or get
this
form
online
at
www.SSA.gov. You may also
get
this
form by
calling 1-800-772-1213. Use Form W-7,
Application
for
IRS
Individual Taxpayer
Identification Number,
to
apply
for
an ITIN,
or
Form SS-4,
Application
for
Employer Identification Number,
to
apply
for
an EIN. You
can
apply
for
an EIN
online
by
accessing
the
IRS
website
at
www.irs.gov/Businesses
and clicking
on
Employer Identification Number
(EIN)
under Starting
a
Business. Go
to
www.irs.gov/Forms
to
view, download,
or print
Form W-7
and/
or
Form SS-4. Or, you can
go to
www.irs.gov/OrderForms
to
place an order
and
have Form W-7
and/or
SS-4
mailed
to
you
within
10 business
days.
If
you are asked
to
complete Form W-9
but do not
have a TIN, apply
for a
TIN and
write “Applied
For”
in the
space
for the
TIN, sign and date
the form,
and give
it to the
requester. For interest and
dividend
payments, and
certain
payments made
with
respect
to
readily tradable instruments, generally
you
will
have 60 days
to get
a TIN and give
it to the
requester before you
are
subject
to
backup
withholding on
payments. The 60-day rule does
not apply
to other
types
of
payments. You
will
be subject
to
backup
withholding on all
such payments
until
you provide your TIN
to the requester.
Note:
Entering
“Applied
For” means
that
you have already applied
for
a TIN
or
that
you
intend to
apply
for
one
soon.
Caution:
A disregarded
U.S.
entity that
has a foreign owner must use
the
appropriate Form
W-8.
Part
II. Certification
To establish
to the withholding
agent
that
you are a U.S.
person,
or resident
alien, sign Form W-9. You may be requested
to
sign
by the withholding agent
even
if item
1, 4,
or
5
below
indicates
otherwise.
For a
joint
account,
only the
person whose TIN is shown
in
Part
I should
sign (when required).
In the
case
of
a disregarded entity,
the
person
identified
on line
1 must sign. Exempt payees, see
Exempt payee
code,
earlier.
Signature requirements.
Complete
the
certification
as
indicated
in
items
1
through
5
below.
Form W-9 (Rev.
11-2017)
For this type
of account:
Give name and SSN
of:
1.
Individual
2. Two
or
more individuals
(joint
account)
other than
an account maintained
by
an FFI
3. Two
or
more
U.S.
persons
(joint
account maintained
by
an FFI)
4. Custodial account
of
a
minor
(Uniform Gift
to
Minors
Act)
5. a. The usual revocable savings
trust
(grantor is also
trustee)
b. So-called
trust
account
that
is
not a
legal
or
valid
trust
under state
law
6. Sole
proprietorship
or
disregarded
entity
owned
by
an
individual
7. Grantor
trust filing
under Optional
Form
1099 Filing
Method 1
(see
Regulations
section
1.671-4(b)(2)(i)(A))
The
individual
The actual owner
of the
account or,
if
combined funds,
the first individual on
the account
1
Each holder
of the account
The
minor
²
The
grantor-trustee
1
The actual
owner
1
The
owner
³
The
grantor*
For this type
of account:
Give name and EIN
of:
8. Disregarded
entity not
owned
by an
individual
9. A valid trust, estate,
or
pension
trust
10. Corporation
or
LLC
electing
corporate
status
on
Form 8832
or
Form
2553
11. Association, club, religious,
charitable,
educational,
or other tax-exempt
organization
12. Partnership
or
multi-member LLC
13. A broker
or
registered
nominee
The
owner
Legal
entity
4
The
corporation
The
organization
The
partnership
The broker
or nominee
1.
Interest, dividend, and barter exchange accounts
opened before
1984
and broker accounts considered active during
1983.
You
must give
For this type
of account:
Give name and EIN
of:
your correct TIN,
but
you
do not
have
to
sign
the certification.
2.
Interest, dividend, broker, and barter exchange accounts
opened
after
1983
and broker accounts considered inactive during
1983. You
must sign
the
certification
or
backup
withholding will
apply.
If
you are
subject
to
backup
withholding
and you are merely
providing
your correct TIN
to the
requester, you must cross
out item
2
in the
certification before signing
the
form.
3.
Real estate transactions.
You must sign
the
certification. You may
cross
out item
2
of the certification.
4.
Other payments.
You must give your correct
TIN,
but
you
do not have
14. Account
with the
Department
of
Agriculture
in the
name
of
a
public
entity
(such as a state
or local
government, school district,
or prison)
that
receives agricultural
program
payments
15. Grantor trust filing under the Form
1041
Filing Method or the Optional Form
1099
Filing Method
2 (see Regulations
section
1.671-4(b)(2)(i)(B))
The
public entity
The
trust
to
sign
the
certification unless you have been
notified that
you
have
previously given an incorrect
TIN.
“Other payments” include payments
made
in the
course
of the
requester’s trade
or
business
for
rents, royalties,
goods
(other
than
bills
for
merchandise), medical and health care services
(including
payments
to
corporations), payments
to
a nonemployee
for services,
payments made
in
settlement
of
payment card and
third
party
network
transactions, payments
to
certain fishing
boat
crew members and
fishermen,
and gross proceeds paid
to
attorneys (including payments
to corporations).
5.
Mortgage interest paid by you, acquisition or abandonment
of
secured property, cancellation
of
debt, qualified
tuition program
payments (under section 529),
ABLE accounts
(under section 529A),
IRA,
Coverdell
ESA,
Archer MSA or HSA contributions or distributions,
and
pension distributions.
You must give your correct
TIN,
but
you
do not have
to
sign
the certification.
What Name and Number To Give the
Requester
1
List
first
and circle
the
name
of the
person whose number you furnish.
If only
one person
on
a
joint
account has an
SSN,
that
person’s number must
be
furnished.
2
Circle
the
minor’s name and furnish
the
minor’s SSN.
3
You must show your
individual
name and you may also enter your
business
or
DBA name
on the
“Business
name/disregarded
entity”
name line. You
may
use either your
SSN
or
EIN
(if
you have one),
but the
IRS
encourages you
to
use your SSN.
4
List
first
and circle
the
name
of the
trust, estate,
or
pension trust. (Do
not
furnish
the
TIN
of the
personal representative
or
trustee unless
the
legal
entity
itself is
not
designated
in the
account title.) Also
see Special rules
for
partnerships,
earlier.
*Note:
The grantor also must provide a Form W-9
to
trustee
of trust.
Note:
If no
name is circled when more
than
one name is listed,
the number
will
be considered
to
be
that of the first
name
listed.
Secure Your Tax Records From
Identity
Theft
Identity theft
occurs when someone uses
your personal information such as
your name, SSN,
or other identifying
information,
without
your permission,
to
commit
fraud
or other
crimes. An
identity thief
may use your SSN
to get
a
job
or
may
file
a tax
return
using your
SSN
to
receive a
refund.
To reduce your
risk:
Protect your SSN,
Ensure your employer is
protecting
your SSN,
and
Be careful when choosing a tax
preparer.
If
your tax records are affected
by identity theft
and you receive a
notice
from the
IRS,
respond
right
away
to the
name and phone number
printed on
the
IRS
notice
or letter.
If
your tax records are
not
currently affected
by identity theft but
you
think
you are
at
risk due
to
a lost
or
stolen purse
or
wallet, questionable credit
card
activity
or
credit report, contact
the
IRS
Identity
Theft Hotline
at
1-800-908-4490
or
submit Form
14039.
For more information,
see Pub. 5027,
Identity
Theft Information
for
Taxpayers.
Victims
of identity theft who
are experiencing economic harm
or
a
systemic
problem,
or
are seeking
help in
resolving tax problems
that
have
not been
resolved
through
normal channels, may be eligible
for
Taxpayer
Advocate
Service (TAS) assistance. You can reach TAS
by
calling
the
TAS
toll-free
case
intake
line at
1-877-777-4778
or
TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing
is
the
creation and use
of
email and websites designed
to mimic legitimate
business emails and websites. The most common act is sending an email
to a
user falsely claiming
to
be an established
legitimate
enterprise
in
an
attempt
to
scam
the
user
into
surrendering private information
that will
be used
for
identity theft.
Form W-9 (Rev.
11-2017)
The IRS does
not initiate
contacts
with
taxpayers via emails. Also,
the
IRS
does
not
request personal detailed information
through
email
or ask
taxpayers
for the
PIN numbers, passwords,
or
similar secret
access
information
for their
credit card, bank,
or other
financial
accounts.
If
you receive an unsolicited email claiming
to
be
from the
IRS,
forward
this
message
to
phishing@irs.gov. You may also
report
misuse
of the
IRS
name,
logo,
or other
IRS
property to the
Treasury Inspector General
for Tax
Administration
(TIGTA)
at
1-800-366-4484. You can forward suspicious
emails
to the
Federal Trade Commission
at
spam@uce.gov
or report them at
www.ftc.gov/complaint. You can contact
the
FTC
at
www.ftc.gov/idtheft
or 877-
IDTHEFT
(877-438-4338).
If
you have been
the victim of identity theft, see
www.IdentityTheft.gov and Pub.
5027.
Visit www.irs.gov/IdentityTheft
to
learn more
about identity theft
and
how
to
reduce your
risk.
Privacy Act
Notice
Section 6109
of the
Internal Revenue Code requires you
to
provide
your
correct TIN
to
persons (including federal agencies)
who
are required
to file
information returns
with the
IRS
to report
interest, dividends,
or
certain
other
income paid
to
you; mortgage interest you paid;
the
acquisition
or
abandonment
of
secured property;
the
cancellation
of
debt;
or contributions
you made
to
an IRA, Archer MSA,
or
HSA.
The person collecting this
form uses
the
information
on the form to file
information returns
with the
IRS,
reporting
the
above information. Routine
uses
of
this information include
giving it
to
the
Department
of
Justice
for civil
and criminal
litigation
and
to
cities,
states,
the
District
of
Columbia, and
U.S.
commonwealths and
possessions
for
use
in
administering
their
laws. The
information
also may be disclosed
to other
countries under a treaty,
to
federal and state agencies
to
enforce
civil and
criminal laws,
or to
federal law enforcement and intelligence agencies
to
combat terrorism. You must provide your TIN
whether
or not
you are
required
to file
a tax return. Under section 3406, payers must generally
withhold a
percentage
of
taxable interest, dividend, and certain
other
payments
to a
payee
who
does
not
give a TIN
to the
payer. Certain penalties may also
apply
for providing
false
or
fraudulent
information.