2025_Vendor_Forms_Version_9.1.25.pdf

Kerry Thomson

MAYOR

CITY OF BLOOMINGTON CONTROLLER’S OFFICE

401 N Morton St Post Office Box 100, Blgtn, IN 47402

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 codes(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 on page II of the IRS Form W-9.

NO PAYMENTS WILL BE ISSUED UNTIL A COMPETED FORM HAS BEEN RECEIVED.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION: SUBSTITUTE W-9

Name of entity/individual. For a sole-proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded entity's name on the line 2:

Business Name/DBA/Disregarded Entity Name here, if different from above:

Address (number, street, and apt. or suite no.):

City, State, and ZIP code:

Telephone number: Fax number: Email:

Check only 1 if you are not a vendor or contractor: Government City Employee Contractual Farmer’s Market Grant Recipient Entertainment

List city department(s) you are doing business with (Parks, Fire, Utilities etc.): Click the drop-down arrow

Products or Services provided. Or if you are a Grant Recipient enter Grant.

Primary NAICS Code: DUNS #:

Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part 1 instructions of IRS Form W-9. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3 of IRS Form W-9

Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give The Requester for guidelines on whose number to enter.

Social security number

Employer identification number

SIGN Signature of HERE U.S. person ► Date ►

SUBSTITUTE W-9 & BANK/EFT FORM

(red boxes are required fields)

(Complete,Save, and Email or Fax form to the City of Bloomington staff-member you are working with)

Please contact our office of you need assistance completing the form or have any questions: controller@bloomington.in.gov or 812.349.3412

Check only one of the following boxes.

Partnership

Partnership Note: Check the “LLC” box above, then click the box for the appropriate code (C, S, P, SM) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should check the box of for the tax classification of its owner.

Other (see instructions) If you checked one of these boxes above: Partnership, Trust/estate, or LLC as Partnership as the tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, then check this box if you have any foreign partners, owners, or beneficiaries.

Exemptions (codes apply only to certain entities, not individuals;

Exempt payee code (if any)

Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)

(Applies to accounts outside the United States.)

Example: 501(c)(3), 501(c)(4), 501(c)(6)

Trust/Estate

Single Member

Check appropriate box for federal tax classification:

Individual/Sole Propriortor LLCs: Enter tax classification of LLC: C corporation

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THE CITY’S PREFERRED METHOD OF VENDOR

PAYMENT IS ELECTRONIC FUNDS TRANSFER (EFT)

DIRECTLY TO THE VENDOR'S BANK. NO PAPER

CHECKS WILL BE ISSUED WITHOUT THE APPROVAL OF

THE CONTROLLER.

PLEASE COMPLETE THE SECTION BELOW TO ENROLL

BANK INFORMATION FOR EFT TRANSFER

Bank Name:

Type of Account: Checking Savings

Routing Number:

Account Number:

Name of Account:

Email for Payment Notification:

For security purposes, please confirm the bank information listed above using one of the methods listed below.

1. Attach or scan a copy of a voided check or deposit ticket for the account above. Counter checks or blank deposit slips will not be acceptable, or

2. A Bank Confirmation Letter (BCL) on bank letterhead confirming the information listed above. The letter must include the name of a bank representative, along with their title and contact information for verification purposes.

3. This information is also required for any bank changes on previously submitted and approved vendor forms

We will not be able to approve or process a form without this documentation.

HOW TO COMPLETE THE W-9 SUBSTITUTE FORM

Please complete and save the form, and email it directly to the City staff member who requested this information.

CITY OF BLOOMINGTON ELECTRONIC FUNDS TRANSFER FORM (EFT)

(Complete and Save form and attach to email)

Email completed forms to: the City of Bloomington Staff Member you are working with. Call 812-349-3412 if you have any questions.

1. Enter your name or business name as shown on your tax returns.

2. If you are doing business under a different name (DBA) enter this name in the second box.

3. Enter your tax classification. See the chart to the right for clarification.

4. Choose your exemptions if applicable.

5. Enter the street address for your home or business.

6. Enter the corresponding city, state, zip code, phone/fax and email address.

7. Enter the City Department who requested you complete this form. Use the drop-down arrow to select from a menu of city departments.

8. Enter the service or product you are providing to the City. Enter GRANT if you are receiving a grant.

9. Enter the tax identification number your taxes are filed under. This will be either a Social Security number, or Employer/Tax Identification number.

a. Sign and date the form.

b. Complete the EFT Form. (attach a copy of a voided check)

c. Return both forms to the email address shown below.

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CITY OF BLOOMINGTON CONTROLLER’S OFFICE