Appendix B W-9, SOS, EFT.pdf

Legal Name

Trade Name -- complete only if doing business as (D/B/A)

Remit Address

Purchase Order Address -- Optional

Individual (Individual's SSN)

Sole Proprietorship (Owner's SSN or Business EIN) SSN

Partnership General Limited

Estate/Trust (Legal Entity's EIN)

Other > (Entity's EIN) Limited Liability Company, Joint Venture, Club, etc.

Corporation Yes No (Corp's EIN)

Government (or Government Operated) Entity (Entity's EIN)

Organization Exempt from Tax under Section 501(a) (Org's EIN) Yes No

Check Here if you do not have a SSN or EIN, but have applied for one. See reverse for information on How to Obtain A TIN Licensed Real Estate Broker? Yes No

Under Penalties of Perjury, I certify that:

(1) (2)

NAME (Print or Type) _______________________________________________ TITLE (Print or Type) _______________________________________

AUTHORIZED SIGNATURE _________________________________________ DATE _______________ PHONE (_______)_____________________

Approved by _________________________________ Date _____________ Action Completed by __________________________ Date _____________

VENDOR: Addition ____ Change ____

615-82-50-7093 (R 4/97)

REQUEST FOR TAXPAYER IDENTIFICATION

NUMBER (TIN) VERIFICATION

(OWNER OF THE EIN OR SSN AS NAME APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS)

DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPIETORSHIP ON THIS LINE - See Reverse for Important Information

Includes corporations providing medical billing services

NOTE: Do not furnish the identification number of the personal representative or trustee unless the legal entity itself is not designated in the account title. List and circle the name of the legal trust, estate, or pension trust.

Note: Enter both the owner's SSN and the business EIN (if you are required to have one)

AGENCY USE ONLY

(SSN = Social Security Number EIN = Employer Identification Number)

NOTE: If no name is circled on a Joint Account when there is more that one name, the number will be considered to be that of the first name listed.

EIN ___ __ -- __ __ __ __ __ __ ___

Do Not enter an SSN or EIN that was not assigned to the legal name entered above

PART II See Part II Instructions on Back of Form

1099: Yes ____ No ____

The number listed on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me) AND 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 (does not apply to real estate transactions, mortgage interest paid, the acquisition or abandonment of secure property, contribution to an individual retirement arrangement (IRA), and payment other than interest and dividends).

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 of under reporting interest or dividends on your tax return. (See Signing the Certification on the reverse of this form.)

THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT

OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.

Agency ____ ____ ____

DO NOT WRITE BELOW THIS LINE RETURN BOTH COPIES TO ADDRESS ABOVE

Do you provide medical services?

Do you provide medical services?

(Partnership'S EIN)

Check legal entity type and enter 9 digit Taxpayer Identification Number (TIN) below:

PRINT OR TYPE RETURN TO ADDRESS BELOW

Substitute Form

W-9 State of Colorado

Do NOT send to IRS

INDIVIDUAL:

SOLE PROPRIETORSHIPS:

ALL OTHER ENTITY'S:

HOW TO OBTAIN A TIN

(3) Real Estate Transactions - You must sign the certification. You may cross out item (2) of the certification if you wish.

Signature -

SUBSTITUTE FORM 1099 INSTRUCTIONS

As soon as you receive your TIN, complete another form W-9, include your new TIN, sign and date the form, and give it to the requester.

Enter the owner's name on the first line; on the second name line you may enter the business name. YOU MAY NOT ENTER ONLY THE BUSINESS NAME. For the TIN, enter both the owner's Social Security Number and the Federal Employer Tax Identification Number (EIN) if you are required to have one.

Enter First and Last name EXACTLY as it appears on your Social Security Card. However, if you have changed your last name, for instance, due to marriage, without informing the Social Security Administration of the name change, please enter your first name and both the last name shown on your social security card and your new last name (IN THAT ORDER). For your TIN, enter your Social Security Number (SSN).

Enter the name of the owner of the EIN or SSN exactly as originally registered with the IRS. The correct TIN is the Employer Identification Number (EIN).

If you do not have a TIN, you should apply for one immediately. To apply for the number, obtain Form SS-05, Application for a Social Security Number Card (for individual), or Form SS-4, Application of Employer Identification Number (for businesses and all other entities), at your local office of the Social Security Administration or the Internal Revenue Service. Complete and file the appropriate form according to its instructions.

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II

DO NOT ENTER AN SSN OR EIN THAT WAS NOT ASSIGNED TO THE LEGAL NAME OF THIS FORM

NAME AND TAX IDENTIFICATION NUMBER (TIN)

CERTIFICATION

FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING

Individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.

If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter you correct TIN in Part I, write "Exempt" in Part II, and sign and date the form.

If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester a completed Form W-8, Certificate of Foreign Status.

To complete Form W-9 if you do not have a TIN, check "Applied For" box in the space indicated in front, sign and date the form, and give it to the requester. For payments that could be subject to backup withholding, you will then have 60 days to obtain a TIN and furnish it to the requester. During the 60-day period, the payments you receive will not be subject to the 31% backup withholding, unless you make a withdrawal.

However if the requester does not receive your TIN from you within 60 days, backup withholding, if applicable, will begin and continue until you furnish your TIN to the requester.

Note: Writing "Applied For" on the form means that you have already applied for a TIN OR that you intend to apply for one in the near future.

- You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item (2) in the certification before signing the form.

- You are not required to sign the certification; however, you may do so. You are required to provide your correct TIN.

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(5) Mortgage Interest Paid by You, Acquisition or Abandonement of Secured Property, or IRA Contribution - You are required to furnish your correct TIN, but you are not required to sign the certification.

(1) Interest, Dividends, and Barter Exchange Accounts Opened Before 1984 and Broker Accounts That Were Considered Active During 1983.

(2) Interest, Dividend, Broker and Barter Exchange Accounts Opened After 1983 and Broker Accounts That Were Considered Inactive During 1983.

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The signature should be an authorized signature, generally the person whose name is on the top line of the form, a partner in the partnership, or an officer of the corporation. For a joint account, only the person whose TIN is shown in LEGAL BUSINESS DESIGNATION should sign the form.

Privacy Act Notice - Section 6109 requires you to furnish your correct taxpayer identificatioon number (TIN) to persons who must file information returns with IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonement of secured property, or contributions you made to an individual retirement arrangement (IRA). IRS uses the numbers for identification purposes and to help verify the accuracy of your tax returns. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 31% of taxable interest, dividend, and certain other payments to a payee who does not furnish a TIN to a payer. Certain other penalties may also apply.

(4) Other Payments - You are required to furnish your correct TIN, but you are not required to sign the certification unless you have been notified of an incorrect TIN. Other payments include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services, payments to a nonemployee for services (including attorney and accounting fees), and payments to certain fishing boat crew members.

EXAMPLE ONLY. CONTRACTORS MUST REGISTER WITH THE

SECRETARY OF STATE AND PRINT OUT THIS PAGE.

rev 08/2017

EFT DIRECT DEPOSIT

AUTHORIZATION FORM

SECTION I (DEPARTMENT USE) - PAYOR, STATE INFORMATION

STATE DEPARTMENT VCUST#

MAILING ADDRESS ADDRESS ID

CITY, STATE, ZIP VERIFIED BY

DEPARTMENT CONTACT

EMAIL PHONE

SECTION II – PAYEE, VENDOR INFORMATION

VENDOR NAME

D/B/A (DOING BUSINESS AS, OPTIONAL)

MAILING ADDRESS

CITY, STATE, ZIP

EMAIL (FOR REMITTANCE ADVICE) PHONE

SECTION III – DEPOSITORY FINANCIAL INSTITUTION AND ACCOUNT INFORMATION

INCLUDE A VOIDED CHECK (NOT A TEMPORARY CHECK OR DEPOSIT SLIP) OR SIGNED

BANK LETTER THAT INCLUDES ALL INFORMATION REQUESTED IN THIS SECTION

BANK NAME BRANCH ADDRESS

ROUTING NUMBER ACCOUNT NUMBER

ACCOUNT TYPE CHECKING SAVINGS FOR FURTHER CREDIT (OPTIONAL)

PAYEE TAXPAYER ID (SSN/EIN)

SHOULD ALL PAYMENTS TO THIS TAXPAYER ID USE THIS BANK ACCOUNT? YES NO

IF NO, PLEASE EXPLAIN

SECTION IV – AUTHORIZATION FOR DIRECT DEPOSIT SET UP, CHANGE, OR CANCEL

SET UP CHANGE CANCEL FOR CHANGES ONLY, PLEASE PROVIDE EXISTING ROUTING & ACCOUNT NUMBER

ROUTING NUMBER EXISTING ACCOUNT NUMBER

I certify that I have the authority to execute this authorization. I herby authorize the State of Colorado to initiate, change, or cancel EFT credit entries (deposits) and if necessary to reverse any incorrect EFT payments made in error to the bank account indicated above. In the event a reversal cannot be implemented, I understand the State will utilize any other lawful means to recover the deposited funds to which the payee was not entitled. This authorization is to remain in full force until the State has received written notification of cancellation in such time as to afford a reasonable opportunity to act on it.

PRINTED NAME TITLE

SIGNATURE DATE