COG_Sub_W9_.pdf
PDF 170 KB Posted
- Attached to
- Workers Compensation 3rd Party Administrator
- Solicitation number
- RFP #26101
- Issued by
- Greenville County, South Carolina
About this file
This file is a Substitute Form W-9 tax identification form issued by the County of Greenville, South Carolina, revised October 2022, for use in connection with a Workers Compensation Third Party Administrator contract opportunity. The form requests standard taxpayer identification information including legal name, DBA/trade name, taxpayer identification number (SSN or EIN/FIN), legal address, entity tax classification, and service type classification. Vendors responding to the County's request for proposals must complete this form to provide Third Party Administration services for the County's self-funded Worker's Compensation claims program. The form specifies that the IRS Form W-9 will not be accepted as a substitute.
The document establishes that the U.S. Taxpayer Identification Number is mandatory per U.S. tax law, with failure to provide the information timely potentially preventing or delaying payment to the vendor. The form requires vendors to certify under penalties of perjury that the taxpayer identification number provided is correct, that they are not subject to backup withholding (or have been notified of exemption status), and that they are a U.S. citizen or other U.S. person. Payment remittance information including contact name, telephone, fax, and email address must also be provided on the form. No specific pricing terms, contract duration, or award timeline information is contained within this document.
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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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File details come from the government source that posted it. Updated .