Appendix C - Substitute W-9 Form.pdf

APPENDIX C: SUBSTITUTE W-9 FORM

DO NOT SEND TO

IRS

► TAXPAYER IDENTIFICATION NUMBER (TIN): ☐ Social Security Number (SSN) Employer Identification Number (EIN) ☐

► BUSINESS NAME & DBA if applicable (must match TIN above):

► Do you collect Sales Tax on behalf of the State of Arizona? YES NO ► If YES, provide Arizona License #: ► Sales/ Use tax rate charged % ► DUNS #:

REMIT TO ADDRESS:

► Street Address Line 1:

► Street Address Line 2:

► City: ► State: Zip:

► Phone: ► Email:

► Accounts Receivable Contact Name:

PROCUREMENT ADDRESS (IF APPLICABLE, PURCHASE ORDER WILL BE EMAILED TO SUPPLIER):

► Street Address Line 1:

► Street Address Line 2:

► City: ► State: Zip:

► Phone: ► Email:

► Purchase Order Contact Name:

► Check appropriate box for federal tax classification; check only ONE of the following seven boxes. See IRS Form W-9 for instructions https://www.irs.gov/pub/irs-pdf/fw9.pdf .

Individual/sole proprietor or single-member

LLC

C

Corporation

S

Corporation

Partnership

Trust/ Estate

Other

Exemption (codes apply only to certain entities, not individuals; see instructions on page 3 of IRS Form linked above):

Exempt payee code (if any):

Exemption from FATCA Reporting code (if any):

(Applies to accounts maintained outside the US)

Limited liability company. Enter the tax classification ► (C=C corporation, S=S corporation, P=Partnership)

Note: For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

FEDERAL SUPPLIER TYPE – Check all that apply:

Service Disabled

Veteran Owned (VD)

Veteran Owned

(VO)

Small Disadvantaged

(SD)

Minority Institution

(MI)

Women Owned

(WO)

HUB Zone (HZ)

CREDIT CARDS

► Does your business accept payment via credit card? YES NO ► If yes, do you charge an additional fee? %

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),

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 I am no longer subject to backup withholding,

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

4. Pursuant to A.R.S. § 38-501 - 38-511 and Yavapai College Policy 2.20, Conflict of Interest, there is no officer or employee of Yavapai

College who has, or whose relative has, a substantial interest in any contract, sale, purchase, or service resulting from this request.

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.

The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

► Signature of U.S. Individual: ► Date:

https://www.irs.gov/pub/irs-pdf/fw9.pdf https://www.azleg.gov/arsDetail/?title=38 https://www.yc.edu/v6/policies/docs/200hr/220-conflictinterest.pdf