2-26-032 - Attachemnt C - 1-420-A W-9 2025.pdf
PDF 734 KB Posted
- Attached to
- Emergency Mitigation Services
- Solicitation number
- 26-032
- Issued by
- Winnebago County, Wisconsin
About this file
This is a Substitute W-9 form (Form 1-420-A) issued by Walworth County, Wisconsin for use in connection with the Emergency Mitigation Services contract opportunity. The form serves as a replacement for the standard IRS W-9 form and is required for all vendors and contractors doing business with Walworth County. Bidders and selected firms must complete this form to provide their taxpayer identification number, business entity classification, and certification of tax compliance. The form requires vendors to designate their entity type (individual/sole proprietor, C corporation, S corporation, partnership, trust/estate, LLC, or other), provide both primary and remit addresses, specify the type of service to be provided, and certify under penalty of perjury that their taxpayer identification number is correct and they are not subject to backup withholding by the IRS. The completed form must be returned to the Walworth County Finance Department in Elkhorn, Wisconsin.
The form was approved and enacted on January 20, 2010, with the most recent revision dated January 17, 2025, ensuring compliance with current tax regulations. Vendors must clearly identify whether they will be issued a 1099 form and whether they are classified as a vendor for Walworth County purposes. Contact information for the Walworth County Finance Department is provided for questions, with phone number 262-741-4333 and fax number 262-741-4384. This documentation requirement applies to all firms submitting statements of qualifications for the Emergency Mitigation Services contract, which includes on-call services for property insurance loss, building and structure loss, natural disasters, and similar emergency response situations.
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Other files
| File | Type | Posted |
|---|---|---|
| 4-26-032 RFQu - final.pdf | ||
| 3-26-032 Attachment B - Sample Goods Services Contract.pdf | ||
| 1-26-032 List of Subcontractors.pdf |
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Text version
Substitute W-9 Walworth County
PRINT OR TYPE DO NOT send to IRS
Please see instructions.
Legal Name (As entered with IRS) If Sole Proprietorship enter your Last, First, MI as exactly stated on your SS card.
Trade Name Business name/disregarded entity name, if different from above
Entity Designation (Check ONE Only) EXEMPTIONS (see instructions):
Individual/Sole Proprietor C Corporation S Corporation Partnership Trust/Estate Exempt payee code (if any)________
LLC, enter the tax classification (C = Corporation, S = S Corporation, P = Partnership) . . . . . ___________
Exempt from FATCA reporting code (if any) ___________
Other (see instructions) __________________________________________________________________
Primary Address (For return of 1099 Form)
PO Box or number and street
City, State, Zip + 4
Remit Address (Where check should be sent if different from primary address) PO Box or number and street
City, State, Zip + 4
Type of Service Provided (Legal, repairs, consulting, etc.)
Taxpayer Identification Number (TIN) Social Security Number
OR
Employer Identification Number
Certification If you have any questions contact:
Under penalties of perjury, I certify that: Walworth County Finance Dept.
Phone: 262-741-4333
1. The number shown on this form is my correct taxpayer identification number, AND
2. I am not subject to 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.
FAX: 262-741-4384
For Agency Use Only
Vendor ID
3. I am a U. S. citizen or other U. S. person (defined in the instructions), AND
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Printed Name ___________________________________________ 1099 - Yes No
Signature ___________________________________________ Phone _____________________ Vendor - Yes No
Title Date
Return this form to:
Walworth County Finance Department
PO Box 1001, Elkhorn, WI 53121
FAX 262-741-4384
Enter your TIN in the appropriate box. The TIN provided must match the name given in the Legal Name Section 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 1. For other entities, it is your employer identification number (EIN). If you do not have a number, see instructios on How do I get a TIN.
Go to www.irs.gov/FormW9 for instructions and the latest information
Request for Taxpayer
Identification Number and Certification
Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C,S or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.
Approved
Enacted 01/20/2010
Revised 01/17/2025
Form 1-420-A
ATTACHMENT C
| Social Security Number: |
| Employer Identification Number: |
| Phone: |
| Entity: Off |
| Title: |
| Legal Name: |
| Trade Name Business: |
| LLC, tax classification: |
| Exempt payee code: |
| Exempt FATCA code: |
| Other, see instructions: |
| Primary Address, PO Box or number and street: |
| Remit Address, PO Box or number and street: |
| Type of Service Provided: |
| Date: |
| Name: |
| Primary Address, City: |
| Primary Address, Zip 4: |
| Remit Address, City: |
| Remit Address, State: |
| Remit Address, Zip 4: |
| Primary Address, State: |
File details come from the government source that posted it. Updated .