SECTION 1: CONTACT INFORMATION AND TAXPAYER IDENTIFICATION NUMBER
NAME (as shown on your income tax return). Name is required on this line; do not leave this line blank.
BUSINESS NAME Disregarded entity name, if different from above.
PRIMARY ADDRESS (number, street, and apt or suite no)
REMITTANCE ADDRESS (number, street, and apt or suite no)
CITY, STATE, and ZIP CODE
REMITTANCE CITY, STATE, and ZIP CODE
SOCIAL SECURITY NUMBER OR EMPLOYER IDENTIFICATION NUMBER New Mexico CRS TAX ID (if applicable)
TAX CLASSIFICATION (check only one)
INDIVIDUAL/ SOLE PROPRIETOR or single-member LLC C CORPORATION S CORPORATION
PARTNERSHIP TRUST/ ESTATE
LIMITED LIABILITY COMPANY– Enter the tax classification (C=C Corporation, S=S Corporation, P=Partnership) ___________
Note: For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
the tax classification of the single- member owner.
501(C)3/ NON-PROFIT ORGANIZATON OTHER (SEE INSRUCTIONS)
EXEMPTIONS (codes apply to certain entities, not individuals; see instructions)
EXEMPT PAYEE CODE (if any)
EXEMPTION FROM FATCA REPORTING CODE (if any)
SECTION 2: CERTIFICATION
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
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
am a U.S. citizen or other U.S. person (defined in the instructions); and
he 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 of
underreporting interest or 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.
he Internal Revenue Service does not require your consent to any provision on this document other than the certifications required to avoid backup withholding.
Section 1- Supplier Information
Information on how to fill out Section 1 can be found at: https://www.irs.gov/pub/irs-pdf/fw9.pdf.
Please return completed document to: Mid-Region Council of Governments, 809 Copper Avenue NW, Albuquerque, NM 87102,
or fax to 505-247-1753 or email to Kim Monjaras at firstname.lastname@example.org.
(Rev. July 2019)
Substitute Form W9
Request for Supplier Information