Form
W-9
Revised December 2017
Commonwealth of Virginia
Substitute W-9 Form
Request for Taxpayer Identification
Number and Certification
Please select the appropriate Taxpayer Identification Number (EIN or SSN) type and
enter your 9 digit ID number . The EIN or SSN provided must match the name given
on the “Legal Name” line to avoid backup withholding. If you do not have a Tax ID
number, please reference "Specific Instructions‐ Section 1." If the account is in more
than one name, provide the name of the individual who is recognized with the IRS as
the responsible party.
Social Security Number (SSN)
Employer Identification Number (E
IN)
Dunn & Bradstreet Universal Numbering System
(DUNS)
(see
instructions)
Legal Name:
Business Name:
Entity Type
Individual
Sole
Proprietorship
Partnership
Trust
Estate
Government
Non‐Profit
S‐Corporation
C‐Corporation
Disregarded
Entity
Partnership
Corporation
Entity Classification
Professional
Services
Politica
l
Subdivision
Real
Estate
Agent
VA
Local
Government
Federal
Gov
ernment
VA
Sta
te
Agency
Medi
cal
Services
Legal
Services
J
oint
Venture
Tax
Exempt
Organiza
tion
OTH
Government
Other
Exemptio
ns (see instructions)
Exempt paye
e code
(if any):
(from backup withholding)
Exemption from FATCA reporting
code (if any):
Contact Information
Legal Address:
City: State : Zip Code:
Remittance Address:
City:
State
:
Zip
Code:
Name:
Email Address:
Corporation
tion 1‐Taxpayer Identification
Se
__ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __
Limited Liability
Company
Business Phone:
Fax Number:
Mobile Phone:
Alternate Phone:
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
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 later in general instructions), 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 instructions titled Certification
Printed
Name:
Authorized U.S. Signature:
Date:
