EHA - W9 From

Form W9

Request for Taxpayer Identification Number and Certification
Vendors and qualfied Independant Contractors, will need to submit the following prior to receiving payment.
- Completed and submitted W9 Form below.
- Invoices for every project or period of service. Including dates of service and description of work or services provided. Invoices should be submitted to yigal@empower-edu.com.
If you have any questions or require additional information, please contact yigal@empower-edu.com or 314-702-7826

Please complete and submit the W9 Form below
1. Name as shown on your income tax return*
2. Business/Entity name, if different from above
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
Part I - Taxpayer Identification Number (TIN)
Social Security NumberEmployer Identification Number
Social Security Number*
Employer Identification Number*
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.
Signature*

Clear
Date*

MonthDayYear
Date
Email Address*
example@example.com
You can check out the details and general instructions below:
Payment Information
Direct DepositCheck
Name on Bank Account*
Bank Account Number*
Bank Routing Number*
CheckingSavings
Should be Empty:

Form W9

Part I - Taxpayer Identification Number (TIN)

Part II - Certification

Payment Information