Request for Taxpayer Identification

Taxpayer Identification Number (TIN)
This form is required to load a vendor into the University's vendor database for payment (please use this form, not the IRS-issued W-9).

This form is considered substantially similar to IRS Form W-9 and must be used in lieu of the IRS form.

Per IRS regulations, the University is required to obtain this information for all persons and organizations receiving payment from us. Without this information, your payments may be subject to 28% backup withholding. You may also be subject to a $50 penalty imposed by the IRS under Section 6723. Federal law on backup withholding preempts any state or local law remedies, such as any right to a mechanic's lien. If you do not furnish a valid TIN, or if you are subject to backup withholding, the University is required to withhold 28% of its payment to you. Backup withholding is not a failure to pay you; it is an advance tax payment. Report all backup withholding as a credit for taxes paid on your federal income tax return.

This form is for vendors located in the United States. International vendors should contact Procurement Services.
1. Name as shown on your income tax return Name is required on this line; do not leave this line blank.*
2. Business name/disregarded entity name, if different from above
3. 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 LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company.Other
If you selected "Limited liability company", enter the tax classification (C=C corporation, S=S corporation, P=Partnership)*
5. Address*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
Contact name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email (for payment notifications)*
example@example.com
Remit Address (if different from above)

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code

Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number
If you are an Individual or Sole Proprietor, enter your Social Security Number (SSN)
A
A
A
-
G
G
-
S
S
S
S
If you are a partnership or a corporation, enter your Federal Employer Identiﬁcation Number (FEIN or EIN).
Employer identification number
X
X
-
X
X
X
X
X
X
X
Retype your Taxpayer Identiﬁcation*Number (TIN):*
Provide numbers only. Do not include dashes or spaces.
EIN Numbers Do Not Match Please Recheck Your Entry
EIN Verify 1
EIN Verify 2

Acknowledgment & Signature
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.
Signature*
Date

MonthDayYear
Date
Signature

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Taxpayer Identification Number (TIN)

Social security number

Employer identification number