03 Att B - Vendor Authorization Form.pdf
PDF 102 KB Posted
- Attached to
- 24-33-SD Route 1 Sewer Replacement
- Solicitation number
- 56854
- Issued by
- Spotsylvania County, Virginia
About this file
The document is a Vendor Authorization and Substitute W-9 Form for Spotsylvania County, Virginia. This form must be completed by all entities to establish a vendor account with Spotsylvania County and provide the necessary certifications as required by the Internal Revenue Service (IRS). The form collects information such as the legal name, doing business as (DBA) name, main and remittance addresses, contact details, taxpayer identification number, and entity classification. The form also includes certification statements regarding backup withholding, U.S. citizenship, and FATCA reporting exemptions.
The related state and local contract opportunity is for the Route 1 Sewer Replacement project in Spotsylvania County, Virginia. The project involves furnishing and installing approximately 5,600-feet of 36-inch sanitary sewer main pipe and all necessary appurtenances. The specifications for this project are dated January 2024, and bids will be received for the construction services and materials required to complete the project.
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| Purpose: To establish a vendor account with Spotsylvania County, all entities must complete this form and provide the necessary certifications as required by the Internal Revenue Service (IRS). The IRS requires entities to complete a substitute W-9 when requested if it is substantially similar to IRS's Form W-9. |
| Entity Name Title: To avoid backup withholding, the legal name provided must match the legal name on file with the IRS for the tax identification number (TIN) provided below. If the account is in more than one name, list first the name of the person whose number matches the TIN provided. |
| Legal Name: Legal Name: |
| Legal Name Fillable: |
| DBA Name: Doing Business As (DBA): |
| DBA Fillable: |
| Main Address: Main Address (Where tax information and general correspondence is to be mailed) |
| Remitt Address Title: Remittance Address (Where payment is to be mailed) |
| Same as Address Text: Same as Main |
| M Address 1: Address Line 1: |
| M Address 1 Fillable: |
| M Address 2: Address Line 2: |
| M Address 2 Fillable: |
| R Address 1: Address Line 1: |
| R Address 2: Address Line 2: |
| M City: City: |
| City Fillable: |
| M State: State: |
| M Zip Code: Zip Code: |
| M Zip Code Fillable: |
| Contact Name: Contact Name: |
| Contact Name Fillable: |
| Contact Title: Title: |
| Contact Title Fillable: |
| Email Fillable: |
| Certification Wording: 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 (including U.S. resident alien); 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 indivdiual 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. While IRS does not require signature for certain types of transactions, the County of Spotsylvania requires signature certifying the accuracy of the information submitted on this form.
| Return Form To: Return Completed Form To: |
| Return Form To Add Text: Office of Accounting & Procurement |
PO Box 215 Spotsylvania, VA 22553 OR: upload to
| Do Not Send: DO NOT send to IRS |
| Social Security #: Social Security Number: |
| OR: OR |
| FEIN: Employer Indentification Number: |
| Exemption: Exemptions - Applies to accounts maintained outside of the U.S. |
| Exempt Payee Code Fillable: |
| Exemption FATCA Fillable: |
| Exemption from FATCA Reporting Code (if any): Exemption from FATCA reporting code (if any) |
| Entity Class Title: Entity Classification |
| Vendor Type Title: Vendor Type: |
| Local Business: Local Business |
| Minority: Minority-owned |
| Small Business: Small Business |
| Woman: Woman-Owned |
| Disabled Vet: Disabled Veteran |
| Department Requesting: Department Requesting Vendor: |
| Dept Requesting Fillable: |
| Department Contact: Department Contact: |
| Dept Contact Fillable: |
| DBA Payable: Payments should be made payable to DBA |
| R City: City: |
| R City Fillable: |
| R State: State: |
| R Zip Code: Zip Code: |
| R Zip Code Fillable: |
| TIN Title: Taxpayer Identification Number (TIN) (Provide ONE Only) |
| R Address 2 Fillable: |
| R Address 1 Fillable: |
| Contact Phone Number Fillable: |
| Contact Phone Number: Contact Direct Phone: |
| Contact Email:: Contact Email: |
| Main Phone Number: Main Phone Number: |
| Main Phone Number Fillable: |
| FEIN Fillable: |
| Entity Type: Off |
| Exempt payee code: Exempt payee code (if any) |
| Individual: Individual |
| Sole proprietorship: Sole proprietorship |
| Single Member LLC: Single member LLC |
| C Corporation: C Corporation |
| S Corporation: S Corporation |
| Partnership: Partnership |
| Government: Government |
| Non-profit: Non-profit |
| LLC - C Corporation: LLC - C Corporation |
| Entity Class: Off |
| Trust or Estate: Trust or Estate |
| Medical services: Medical services |
| Legal Services: Legal Services |
| Real estate: Real estate |
| Other: Other |
| Vendor type note: (Check all that apply) |
| Entity Type Title: Business Type: |
| Entity Type comment: (Check only one of the following boxes) |
| Entity Class comment: (Check one of the following boxes) |
| Small Bus note: - # of employees |
| SSN Fillable: |
| Employee # fillable: |
| Certification header: Certification |
| Vendor identificaiton & tax header: Contact and Taxpayer Identification Information |
| Authorized Signature: Authorized Signature: |
| Title: Spotsylvania County Vendor Authorization and Substitute W-9 Form |
| R State Fillable: |
| M State Fillable: |
| Printed Name Field: ______________________________________________________________________________________________________ |
| Signature Name Field: ______________________________________________________________________________________________________ |
| Printed Name - Fillable: |
| Signature Name - Fillable: |
| Signing Title: Title: |
| Date: Date: |
| title Fillable: |
| Date Fillable: |
| Printed Name: Printed Name: |
| Internal Use: Internal Use Only: |
| Reset: |
| Remit address Same: Off |
| Payable DBA Check Box: Off |
| Vendor type1: Off |
| vendor type2: Off |
| vendor type3: Off |
| vendor type4: Off |
| vendor type5: Off |
| LLC - S Corporation: LLC - S Corporation |
| LLC - Partnership: LLC - Partnership |
| Upload link: www.spotsylvania.va.us/vendor-form |
| Instructions note: Please see IRS Form W-9 instructions for assistance. Instructions can be found at www.irs.gov/FormW9. |
| Ext:: Ext: |
| Ext Fillable: |
| Early discount check box: Off |
| early discount question: Check this box and provide a contact name and email below if your organization offers early payment discounts. |
| early payment discount name and email: |
| Ext Fillable2: |
| Questions: For questions with this form please contact the Office of Accounting & Procurement at 540-507-7576. |
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