3-26-036 Attachment B 1-420-A W-9 2025.pdf
PDF 170 KB Posted
- Attached to
- Employee Service Recognition Awards Program
- Solicitation number
- 26-069
- Issued by
- Winnebago County, Wisconsin
About this file
This is a Substitute W-9 form (Form 1-420-A) issued by Walworth County, Wisconsin, designed for vendors providing services to the county. The form serves as a Request for Taxpayer Identification Number and Certification, requiring vendors to provide their legal name, business entity designation, taxpayer identification number (either Social Security Number or Employer Identification Number), primary and remittance addresses, and the type of service being provided. Vendors must certify under penalty of perjury that their taxpayer identification number is correct, that they are not subject to backup withholding, and that they are a U.S. citizen or other U.S. person. The form indicates whether the vendor will be issued a 1099 form and whether they are classified as a vendor for county purposes. Completed forms should be returned to the Walworth County Finance Department at PO Box 1001, Elkhorn, WI 53121, via mail or facsimile at 262-741-4384, with questions directed to the Finance Department at 262-741-4333.
This form is specifically associated with Walworth County's Employee Service Recognition Awards Program procurement, which seeks a qualified vendor to provide recognition items and professionally produced certificates for employees reaching service milestones at one year and each subsequent five-year increment thereafter. The W-9 form is a standard administrative requirement that must be completed and submitted by any vendor seeking to do business with Walworth County, establishing the vendor's tax status and payment information for 1099 reporting purposes.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-26-069 Attachment A Sample Contract.pdf | ||
| 1-26-069 Employee Service Award RFP.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
| 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 .