23RFP8565 Substitute_W-9_SD_Fillable.pdf

State of South Dakota

BFM-0001 (V03/201907)

Substitute W-9

SEND TO THE STATE AGENCY

YOU SEND INVOICES

DO NOT send to IRS

Taxpayer Identification Number (TIN) Verification Print or Type Please see attachment or reverse for complete instructions.

This form can be made available in alternative formats to qualified individuals upon request.

Legal Name (as entered with IRS) If Sole Proprietorship enter your Last, First MI

Entity Designation (check only one) Required

Individual / Sole Proprietor Partnership C Corporation S Corporation Limited Liability Company - Individual Limited Liability Company - Partnership Limited Liability Company - Corporation Governmental Entity Hospital Exempt from Tax or Government Owned

Long Term Care Facility Exempt from Tax or Government Owned

Trust/Estate All Other Entities (specify e.g. 501(c)(3), etc.)

Taxpayer Identification Number (TIN)

Business Name If doing business as (DBA) or enter business name of Sole Proprietorship

Order Address (where order should be mailed) PO Box or Number and Street, City, State, ZIP + 4

Remit Address (where check should be mailed) PO Box or number and street, City, State, ZIP + 4

Exemptions Check Only One Required

Social Security Number (SSN) Employer Identification Number (EIN) Individual Taxpayer Identification Number for U.S. Resident Aliens (ITIN)

Exempt payee code (if any):

Exemption from FATCA reporting code (if any):

Certification Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number, AND

2. I am not subject to back up 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 back up 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.

3. I am a U.S. person (including a US resident alien).

Printed Name Printed Title Telephone Number

Signature Date (mm/dd/yy)

Optional Direct Deposit Information Your Bank Account Number Checking

Savings Bank Routing Number (9-digit ABA #) Name on Bank Account

THIS IS A:

new direct deposit change of existing (providing old banking information required to change existing)

Old Bank Account Number Old Routing Number (9-digit ABA #) You must provide the previous banking information to make a change.

Required e-mail address (Please make this LEGIBLE)

If you provide an email address you will be sent electronic notification when a payment is issued. You will also receive a PIN for use when logging into the SD Vendor Self Service website at http://bfm.sd.gov/vendor. We will NOT share your email address with anyone or use it for any purpose other than communicating remittance information.

Information below to be completed by the State Agency. Vendor Number required for any new vendors added to SDAS.

State Agency: Agency Contact: Date: Vendor Number assigned by SDAS: