AccuParts W-9 and Direction of Pay

Form W-9 (Rev. October 2018) 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.
Name as shown on your income tax return Name is required on this line; do not leave this line blank.
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 single-member LLC
Specific Instructions
Address number, street, and apt. or suite noSee instructions.*
City*
State*
Zip Code*
Taxpayer Identification Number (TIN)
Social security number- Nine digits, no dashes*
example- 222335555
Part II
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 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
Enter Your Full Name Here:
Entering your full name here constitutes your signature for the purposes of this document
Date
Date

MonthDayYear
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.
- 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.
What is the name of the Store where you are signing up to count?*
ex- Williams Ford
Please include the city and state of the store.*
ex- Atlanta, GA.
Please Provide the Date of the count.*

MonthDayYear
Date
AccuParts Direct Pay- For Electronic Payment
Payee
Please enter payee and account-related information for the payee
First Name:
MI:
Last Name:
Mobile #:
Please enter a valid phone number.
Primary Email: (for notification of Payment)
example@example.com
Secondary Email: (for notification of Payment)
example@example.com
Payee Account Information
Note: Please enter the bank routing and account number of your payee after you have confirmed with your payee the appropriate routing number that may be used for electronic payments. Bank routing numbers that appear on your payee's check do not always support electronic payments. (See illustration below)
Routing Number:

Nine Digits Only
Account Number:
Account Type:
AccuParts Mailed Check

**Please only complete this form if you DO NOT wish to be paid electronically**
Payee
Please enter payee and address-related information for the payee. ONLY if you choose not to have your payment direct deposited into your bank account.
First Name:
MI:
Last Name:
Mobile #:
Phone Number
Please enter a valid phone number.
Primary Email: (for notification of Payment)
example@example.com
Secondary Email: (for notification of Payment)
example@example.com
Payee Address Information
House # :
If Applicable
Unit/Apt # :
If Applicable
Street Address Line 1:
Ex: 1234 Main Street
Street Address Line 2:
If applicable
City:
State:
Zip:
By typing my name and pressing submit on this electronic form I hereby certify that the banking and/or mailing address information is true and accurate. I furthermore agree to not hold AccuParts/A2CX MGMT LLC responsible for any errors or omissions in the information I have provided on this form that may cause a delay in receipt of payment.*
Type legal name here before pressing submit.
Should be Empty:

Request for Taxpayer Identification Number and Certification

Specific Instructions

Taxpayer Identification Number (TIN)

Part II

Certification

Sign Here

Date

General Instructions

Purpose of Form

AccuParts Direct Pay- For Electronic Payment

Payee

First Name:

MI:

Last Name:

Mobile #:

Payee Account Information

Routing Number:

Account Number:

Account Type:

AccuParts Mailed Check

Payee

First Name:

MI:

Last Name:

Mobile #:

Payee Address Information

House # :

Unit/Apt # :

Street Address Line 1:

Street Address Line 2:

City:

State:

Zip: