Attachment 2 - AO-213.pdf

AO 213 (Rev. 9/19)

REQUEST FOR VENDOR INFORMATION AND TIN CERTIFICATION

Refer to the instructions page for further information on completing this form.

Part 1 Payee Information Line 1. Payee Name:

Line 2. Additional payee information: (if applicable)

Part 2 Business Name (if different from above)

Part 3 Enter your TIN in the appropriate box.

The TIN provided must match the name given in Part 1, Line 1.

Enter only an EIN or SSN - NOT BOTH.

EIN: -

SSN: - -

Part 4 DUNS # (if applicable) Part 5 Select the appropriate box below for U.S. tax classification for person or entity listed in Part 1, Line 1.

” Individual or single member LLC ” Corporation (Payments related to medical or healthcare service providers)

” LLC (Except single member) ” Corporation (All other payments not met by corporation category above)

(Select one:) ” C Corp ” S Corp ” Partnership ” Partnership ” Trust/Estate ” Other: _____________________ Part 6 Mailing Address (where payments, orders, and IRS 1099 forms will be sent) Street address:

City: State: Zip code:

Point of Contact (if different from Part 1, Line 1 above) Name:

Phone #: Email Address:

Part 7 Additional Address Information (if different from above) Street address:

City: State: Zip code:

Part 8 Electronic Funds Transfer (EFT) Information (OPTIONAL) Owner(s) name as it appears on bank account:

Bank Name: Routing #: (Must contain 9 digits) Payee must select an account type: (Select one) ” Checking ” Savings Account Number: (do not include check number) Part 9 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 backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest and dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined in the instructions).

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Signature: Date:

For Judiciary Use Only Select those boxes that apply: ” Addition ” Change Vendor Code:

” Active ” Inactive Vendor Type:

(Trustee or Vendor)

Vendor Administrators: Attach this form to the JIFMS MANL document. This form can also be submitted, subject to separation of duties requirements, via HEAT at: https://nsms.ao.dcn. The service request can be found under Financial Management Services> JIFMS Vendor Additions or Updates. For FAS4T users (CCAM only), send this form to the local court vendor administrator. For questions regarding JIFMS and court FAS4T, please contact the National Support Desk at (210) 536-5000. This form should be completed including the vendor's signature and submitted by Judiciary staff only.

Sensitive information must be securely maintained and only visible to designated staff.

General Instructions

Purpose of the AO 213 The Judiciary utilizes the AO 213 to collect information necessary to facilitate payment by EFT or U.S. Treasury check.

For many payments, the Judiciary is required to file an information return (e.g., 1099-MISC; 1099-INT) with the IRS and, therefore, must obtain payees’ correct names and associated TINs to do so. If a TIN is not provided, a payee may be subject to backup withholding – situations where the judiciary must withhold a certain percentage to ensure the IRS receives any tax due on the payment.

Payments disbursed by the U.S. Treasury on the judiciary’s behalf must collect payee TINs to comply with the U.S. Treasury’s TIN Policy.

Payee TINs, obtained through this form, may be used by the government to collect and report on any delinquent amounts arising out of the payee’s relationship with the government.

Part 1, Line 1 Do not leave this line blank. Enter only one name for you or your entity. The name should match the name on your or your entity’s U.S.

tax return.

Individual. Generally, enter the name shown on your U.S. tax return. If you have changed your last name without informing the Social Security Administration of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note: For Individual Taxpayer Identification Number (ITIN) applicants, enter your name as it was entered on your IRS Form W-7 application, line 1a.

Sole Proprietor or Single-Member LLC. Enter your name as shown on your IRS 1040/1040A/1040EZ in Part 1. You may enter your business name or “doing business as” (DBA) name in Part 2.

Partnership, LLC (Except Single-Member LLCs), or Corporations.

Enter the entity’s name as shown on the entity’s U.S. tax return in Part 1 and any business name or DBA name in Part 2.

Other entities. Enter your name as shown on required U.S. tax documents in Part 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business name or DBA name in Part 2.

Part 1, Line 2 If this form is being completed so that a U.S. Treasury check may be issued payable to more than one person or entity, or if an EFT payment will be issued to an account owned jointly, enter in Part 1, Line 1 the name of the person or entity whose TIN you entered in Part 3. Additional names for joint accounts or for other payees (“and,” “or,” or “care of”) must be entered in Part 1, Line 2.

If payment is to be made by… Then, enter the following… EFT to Payee 1 AND Payee 2, co-owners of a joint account

Payee 1’s name in Part 1, Line 1;

Payee 2’s name in Part 1, Line 2;

Payee 1’s TIN in Part 3.

U.S. Treasury check made payable to Payee 1, Payee 2, AND Payee 3.

Payee 1’s name in Part 1, Line 1;

Payee 2’s name AND Payee 3’s name in Part 1, Line 2;

Payee 1’s TIN in Part 3.

U.S. Treasury check made payable to Payee 1, Payee 2, OR Payee 3.

Payee 1’s name in Part 1, Line 1;

Payee 2’s name OR Payee 3’s name in Part 1, Line 2;

Payee 1’s TIN in Part 3.

U.S. Treasury check made payable to Payee 1, CARE OF (c/

o) Power of Attorney

Payee 1’s name in Part 1, Line 1;

C/O Power of Attorney name in Part 1, Line 2;

Payee 1’s TIN in Part 3.

Part 2 If you have a business or DBA name, you may enter it in Part 2.

Part 3 Enter your or your entity’s TIN in the appropriate box. The TIN must be the TIN associated with the one person or one entity listed in Part 1, Line 1.

If you are a resident alien and you do not have – and are not eligible to get

– an SSN, your TIN is your ITIN. Enter it in the social security number box.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.

If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Part 4 If applicable, enter your entity’s DUNS number, Part 5 Check the appropriate box in Part 5 for the U.S. tax classification of the person or entity’s whose name is entered in Part 1. Check only one box in Part 5.

Part 6 Enter your address (number, street, and apartment or suite number). This is where your paper U.S. Treasury check and any information returns (e.g., 1099-MISC; 1099-INT), if applicable, will be mailed.

Enter a point-of-contact name, email, and phone number. A point of contact is necessary if an entity is listed in Part 1, Line 1 or a point-of-contact is different than an individual listed in Part 1, Line 1.

Part 7 If you have an additional address other than the address listed in Part 6, such as a physical address that differs from a mailing address for payment and information returns, enter it here.

Part 8 The Routing Number must be nine digits. If you are unsure of your Routing or Account Numbers, consult your financial institution.

You must identify your account as either checking or savings to ensure our payment is accepted by your financial institution.

Part 9 You must cross out item 2 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.

For item 3, you are considered a U.S. person, for federal tax purposes, if you are:

• An individual who is a U.S. citizen or U.S. resident alien;

• A partnership, corporation, company, or association created or organized in, or under the laws of, the United States;

• An estate (other than a foreign estate); or

• A domestic trust (as defined in Regulations section 301.7701-7).

For a joint account, only the person whose TIN is shown in Part 3 should sign.

https://www.fiscal.treasury.gov/tin/policy-directive.html