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