Attachment H-Payee Registration and W-9.pdf

Statewide Payee Registration Washington State

STEP 1: Is this a NEW registration or CHANGE to an existing registration (check one)?

NEW REGISTRATION

CHANGE to EXISTING REGISTRATION – complete the ENTIRE form and check below what is updated:

If you know your Statewide Vendor Number, enter it here:

STEP 2: Enter information about the payee and contact person

Legal Name of Payee as it appears on federal tax forms (see W-9) SSN OR EIN

Business Name, if different from Legal Name above – e.g. Doing Business As (DBA) Name Contact Person

Mailing Address

( ) - Ext.

Contact Telephone Num ber

City, ST and Zip Code

Contact Fax Number

Email to receive Statewide Vendor Number and payment notifications Agy#/Owner-Int./System/Identifier STATE USE ONLY

Type of Business

STEP 3: Select Payment Option:

Direct Deposit to bank (recommended) or Check in US mail (terminates any previous banking information on file)

STEP 4: For Direct Deposit, complete all fields below and sign

Financial Institution Name – must be a US institution Financial Institution Phone Number

Routing Number – see example at right Account Number – see example at right In addition to providing your banking information on this form, you may also attach a voided check.

Account Type: Checking or Savings (Checking will be used if neither box is marked.)

Authorization for Direct Deposit:

I hereby authorize and request the Department of Enterprise Services (DES) and the Office of the State Treasurer (OST) to initiate credit entries for payee payments to the account indicated above, and the financial institution named above is authorized to credit such account. I agree to abide by the National Automated Clearing House Association (NACHA) rules with regard to these entries. Pursuant to the NACHA rules, DES and OST may initiate a reversing entry to recall a duplicate or erroneous entry that they previously initiated. I understand that, if a reversal action is required, DES will notify this office of the error and the reason for the reversal. This authority will continue until such time DES and OST have had a reasonable opportunity to act upon written request to terminate or change the direct deposit service initiated herein.

Authorized Representative (Please Print) Title

SIGNATURE of Authorized Representative Date routing number (nine digits) account number (can vary in length)

PLEASE

DO NOT

STAPLE

Name/DBA Contact Information Email Payment Options Direct Deposit Additional InformationAddress jenessac Typewritten Text jenessac Sticky Note Accepted set by jenessac

Revised 7/09/2013

STEP 5: Complete and sign the Request for Taxpayer Identification Number (W-9) Substitute

Form W-9 Request for Taxpayer

Identification Number and Certification

1. Legal Name (as shown on your income tax return)

2.Business Name, if different from Legal Name above – e.g. Doing Business As (DBA) Name

3.Check ONLY ONE box below (see W-9 instructions for additional information)

Individual or Sole Proprietor

LLC filing as a sole proprietor

Partnership

Corporation

S-Corp

LLC filing as Corporation

LLC filing as Partnership

LLC filing as S-Corp

Non Profit Organization

Volunteer

Board /Committee Member

Local Government

State Government

Federal Government (including tribal)

Tax-exempt organization

Trust/Estate

4. For Corporation, S-Corp, Partnership or LLC, check one box below if applicable:

Medical Attorney/Legal

5. If exempt from backup withholding, check here:

number, street, and apt. or suite no.)

For office use

The Legal Name, Address and TIN must be filled in completely and the document signed for the forms to be accepted.

7. City, state, and ZIP code

8.Taxpayer Identification Number (TIN) Enter your EIN OR SSN in the appropriate box to the right (do not enter both)

For individuals, this is your social security number (SSN).

For other entities, it is your employer identification number (EIN).

NOTE: The EIN or SSN must match the Legal Name as reported to the IRS. For a resident alien, sole proprietor, or disregarded entity, or to find out how to get a Taxpayer Identification Number, see the W9 Instructions. If the account is in more than one name, see the W9 Instructions for guidelines on whose number to enter.

Social security number

OR

Employer identification number

9. Certification Under penalty of perjury, I certify that:

• The number shown 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, and

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

SIGNATURE of U.S. PERSON Date

6. Address ( http://www.des.wa.gov/SiteCollectionDocuments/ContractingPurchasing/vendorW9Instructions.pdf jenessac Typewritten Text jenessac Typewritten Text http://www.des.wa.gov/services/ContractingPurchasing/Business/VendorPay/Pages/default.aspx jenessac Typewritten Text

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