DHHS91073 Form 3 - Substitute Form W-9.pdf

Rev. 6/30/22

State of Utah, Department of Health and Human Services (DHHS)

SUBSTITUTE FORM W-9:

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER & CERTIFICATION

TYPE OR PRINT INFORMATION NEATLY. PLEASE REFER TO INSTRUCTIONS FOR MORE INFORMATION.

Part I: Taxpayer Information

1. Full Legal Business Name: 2. Doing Business As (DBA) Name (if applicable):

3. Federal Tax Classification: (CHECK ONLY ONE BOX)

Partnership Governmental Entity LLC taxed as Corporation LLC taxed as Partnership

Individual/Sole Proprietor

LLC taxed as Sole Proprietor For-Profit Corporation Nonprofit Corporation Other (specify)_________________________________________________________________

4. Exemptions:

Exempt Payee Code (if any) ____________________

Exempt from FATCA reporting code (if any) ____________________

(Applies to accounts maintained outside the U.S.)

Part II: Taxpayer Identification Number (TIN) & Taxpayer Identification Type

1. Enter your TIN here: (DO NOT USE DASHES) See instructions.

2. Taxpayer Identification Type: (CHECK ONLY ONE BOX)

Employer ID No. (EIN) Social Security No. (SSN) Individual Taxpayer ID No. (ITIN)

Part III: Address

1. Legal Address:

Number, Street, and Apartment or Suite Number City, State, and Zip Code

Part IV: Certification (If this form is signed, the signature should be provided by the individual, owner, officer, legal representative, or other authorized person of the entity listed on the form.)

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct Taxpayer Identification Number, and

2. I am a U.S. citizen or other U.S. person, and

3. I am not subject to backup withholding because: (a) I am exempt from back up withholding, (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

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification Instructions. You must cross out item 3 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.

A signature is required:

Signature of U.S. Person

Title Date

Print Name Email Address Phone Number

DO NOT SUBMIT FORM TO IRS – SUBMIT FORM TO DHHS ONLY AS DIRECTED

Rev. 11/19 State of Utah, Department of Health and Human Services (DHHS)

Instructions for Completing Substitute Form W-9

DHHS must obtain the taxpayer’s full legal business name, federal tax classification and

Taxpayer Identification Number (TIN) to report income paid to it. DHHS uses the Substitute

Form W-9 to obtain certification of its TIN in order to ensure accuracy of information contained in its payee/vendor databases and to avoid backup withholding1. DHHS asks for the information on the Substitute Form W-9 to comply with Internal Revenue Service laws. Any payee/vendor who wishes to do business with DHHS must complete the Substitute Form W-9. Payees/

Vendors of DHHS are required to give DHHS this information.

Part I: Taxpayer Information2

1. Full Legal Business Name:

a. Organizations: Enter the name shown on its charter or other legal documents creating the organization. Do not abbreviate the full legal business name or omit any portion of it, such as ending with “Inc.” or “LLC”.

b. Individuals: Enter the name of the person as it appears on the individual’s Social

Security card or other required federal tax documents.

2. Doing Business As (DBA) Name: Enter the DBA name or disregarded entity name.

3. Federal Tax Classification: Check the appropriate federal tax classification or check

“Other” and specify the appropriate federal tax classification not otherwise listed.

4. Exemptions: Refer to IRS Form W-9 instructions for an explanation of exemptions.

Part II: Taxpayer Identification Number (TIN) and Taxpayer Identification Type The TIN provided must match the name in the “Full Legal Business Name” box to avoid backup withholding. For individuals, this is your Social Security Number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, refer to IRS W-9 instructions for additional information. For other entities, it is your Employer Identification Number (EIN). If you do not have a number or if the account is in more than one name, refer to IRS W-9 instructions for additional information.

1. Taxpayer Identification Number (TIN): Enter taxpayer’s nine-digit Employer

Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer

Identification Number (ITIN).

2. Taxpayer Identification Type: Check the type of identification number provided.

Part III: Address Provide the full legal address. PO Boxes not accepted.

Part IV: Certification

A signature is required. The name or signature should be provided by the individual, owner, officer, legal representative, or other authorized person of the entity listed on the form.

1 According to IRS Regulations, DHHS must withhold 28% of all payments if a payee/vendor fails to provide DHS its certified TIN. The Substitute Form W-9 certifies a payee/vendor’s TIN.

2 A Utah-based payee/vendor that is required to register with the State of Utah, Department of Commerce

(Commerce) should ensure its full legal business name, federal tax classification, and any DBA provided match its registration with Commerce.