COG_Sub_W9_.pdf
PDF 170 KB Posted
- Attached to
- ELECTRONIC PATIENT CARE (ePCR) SOFTWARE SYSTEM
- Solicitation number
- RFP #26061
- Issued by
- Greenville County, South Carolina
About this file
This is a Substitute Form W-9 document issued by the County of Greenville, South Carolina, for use in the procurement of an Electronic Patient Care Reporting (ePCR) software solution for Greenville County Emergency Medical Services (GCEMS). The form serves as a tax identification document required from vendors responding to the County's sealed proposal solicitation for ePCR software that will support the delivery of 911 emergency medical services, including Basic Life Support (BLS) and Advanced Life Support (ALS), as well as dispatch services for twenty local fire departments. The County of Greenville has established this document as a mandatory substitute for IRS Form W-9 (as revised October 2022) and must be completed by all prospective vendors prior to contract award and payment processing.
The form requires vendors to provide complete legal name, tax identification information, entity classification, service type designation, payment remittance address, and contact information. Vendors must certify under penalty of perjury that the taxpayer identification number provided is correct, that they are not subject to backup withholding by the Internal Revenue Service, and that they are a U.S. citizen or U.S. person. The County notes that failure to provide this information in a timely manner could prevent or delay payment to the successful vendor. This document is a prerequisite administrative requirement within the County's procurement process and does not itself contain pricing terms, contract duration, renewal options, or other substantive contract specifications.
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Other files
| File | Type | Posted |
|---|---|---|
| ELECTRONIC_PATIENT_CARE_(ePCR)_SOFTWARE_SYSTEM.pdf | ||
| RFP_for_ePCR.docx | DOCX document | |
| Sample_Services_Agreement.pdf |
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Text version
COUNTY OF GREENVILLE SUBSTITUTE FORM W-9
(IRS Form W-9 will not be accepted in lieu of this form) Revised October 2022
Legal Name (as shown on tax return) DBA/Trade Name
Taxpayer Identification Type TIN (Must match legal name)
__ SSN __ EIN/FIN ________________________
Legal Address (number, street & apt. or suite no.) City, State & Zip code
Entity Tax Classification (Choose only one) Service Provided (Must select a type)
__ Individual/Sole Proprietorship or Single-member LLC __ Medical or Veterinarian service
__ Partnership __ LLC-Partnership __ Legal /Attorney Service
__ C Corporation __ LLC - C- Corp __ Rental of Real Property
__ S Corporation __ LLC- S - Corp __ Products / Services type _____________
__ Other __ Trust /Estate ________________________________
_______________________________________ __ Other (Specify) _____________________
The U.S. Taxpayer Identification Number is being requested per U.S. tax law. Failure to provide in a timely manner could prevent or delay payment.
Payment Remittance Information
Address (number, street & apt. or suite no.) City, State & Zip code
Contact Name Telephone #
Fax # E-mail
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);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 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
3) I am a U.S. citizen or other U.S. person.
Sign Here Date
| Legal Name as shown on tax return: |
| DBATrade Name: |
| TIN Must match legal name: |
| Legal Address number street apt or suite no: |
| City State Zip code: |
| undefined: |
| Products Services type: |
| Other: |
| Other Specify: |
| Address number street apt or suite no: |
| City State Zip code_2: |
| Contact Name: |
| Telephone: |
| Fax: |
| Email: |
| Sign Here: |
| Date: |
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