W-9 - MSA Contracts

Form W-9

Taxpayer Identification Number Request

VENDOR NAME:

VENDOR ADDRESS:

CITY:

STATE:

ZIP:

EMAIL:

Please complete the following information. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide us with this information, your payments may be subject to a 30% federal income tax backup withholding. Also if you do not provide us with this information, you may be subject to a $50 penalty imposed by the Internal Revenue Service under section 6723.

Use this form only if you are a U.S. person (including U.S. resident alien). If you are a foreign person, use the appropriate Form W-8.

Part 1 Tax Status: (Choose one status and complete the associated boxes)

Individual/Sole Proprietor: A sole proprietorship may have a trade name (doing business as), but the legal name is the name of the business owner.

	Business or Trade Name:
	Business Owner's Name: (if different)
	Business Owner's Employer Identification Number:	- Do not use your social security number.

Partnership: A Partnership may have a trade name (doing business as), but the legal name is the list of the names of the partners.

	Name of Partnership:
	Partnership's Employer Identification Number:	-
	Partnership's Legal Name (Name of First Partner):

Limited Liability Company (LLC)

	Name of LLC:
	Employer Identification Number:	-

Corporation, exempt charity, or other entity: A corporation may use an abbreviated name, but the legal name is the name on the articles of incorporation.

	Name of Corporation or Entity:
	Employer Identification Number:	-
	Are you exempt from Form 1099 reporting?	Yes No (Legal or Medical company)
	If you are exempt from Form 1099 reporting, please choose one:

Part 2 Certification: I certify under penalty of perjury that the Tax Identification Number I have provided is correct. I am a U.S. person (including a U.S. resident alien).

Person completing this form:

Date:

Phone: