U.S. House of Representatives
Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form
FAX NUMBER:
SECTION I UNITED STATES HOUSE OF REPRESENTATIVES INFORMATION
ADDRESS US HOUSE OF REPRESENTATIVES - ACCOUNTING, 3110 O'NEILL HOUSE OFFICE BUILDING, WASHINGTON DC 20515
AGEN
CY IDENTIFIER
53-6002523
AGENCY LOCATION CODE 4832 TELEPHONE NUMBER (202) 226-2277
SECTION II PAYEE/COMPANY INFORMATION
BUSINESS NAME/DISREGARDED ENTITY NAME OR DBA, IF DIFFERENT THAN NAME
ON YOUR INCOME TAX RETURN
ADDRESS/CITY/STATE/ZIP Enter the correct Tax Identification Number type
SOCIAL SECURITY NUMBER (SSN) EMPLOYER TAX ID NUMBER (EIN)
CONTACT PERSON NAME PURCHASE ORDER ADDRESS/CITY/STATE/ZIP
PO EMAIL
TELEPHONE NUMBER FAX NUMBER TELEPHONE NUMBER FAX NUMBER
REMIT TO ADDRESS
CHECK APPROPRIATE BOX FOR FEDERAL TAX CLASSIFICATION (required)
Partnership
Trust/Estate
C Corporation
SECTION III FINANCIAL INSTITUTION INFORMATION
BANK NAME TELEPHONE NUMBER
NINE-DIGIT ROUTING TRANSIT NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___
DEPOSITOR ACCOUNT TITLE
DEPOSITOR ACCOUNT NUMBER
LOCKBOX NUMBER
TYPE OF ACCOUNT 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
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
NAME TITLE/POSITION
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.
NAME AS SHOWN ON YOUR INCOME TAX RETURN
Exemptions (codes apply only to certain
entities, not individuals):
Exempt payee code (if any)
Exemption from FATCA reporting code
(if any)
(Applies to accounts maintained outside
the U.S.)
U.S.)
S Corporation
Individual/Sole Proprietor or
Single Member LLC
Limited Liability Company. Check the tax classification: C corporation S corporation Partnership
Note. For a
single-member LLC
that is disregarded, check the appropriate box for the tax classification of the single-member owner.
Government Entity. Check the tax classification:
Federal State Local
Other
USHR v. 112017 ms
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