ESBD_399060_1740512368322_Form 5-Substitute W-9 and Direct Deposit Form.docx

TWC Substitute W-9 and Direct Deposit Form

Box 1 Box 2 Box 3 Legal Name (as shown on your tax return):

Business Name (if different from Box 1):

Tax Information Mailing Address:

Employer Identification Number (EIN)

If Other, please explain:

Partner 1 SSN/EIN:

Partner 2 Name:

Partner 2 SSN/EIN:

Please see IRS Website Exempt from Backup Withholding

TWC1020

(06/18) Page of

Direct Deposit Information (Response Required)

Financial Institution Name:

Financial Institution Address: City: State: Zip:

Box 14 Box 15 Will payments be forwarded to a financial institution outside the United States? Yes No

Certification of TWC Substitute W-9 and Direct Deposit Form

Under penalties of perjury, I certify that:

1) I have provided my correct taxpayer identification number and that;

2) I am not subject to backup withholding as specified on the instruction page for this form and that;

3) I am a US citizen or other US person and that;

4) For Direct Deposit Authorization Setup, Changes or Cancellation I authorize the Texas Comptroller of Public Accounts to deposit my payments from the State of Texas to my financial institution electronically. I understand that the Texas Comptroller of Public Accounts will reverse any payments to my account in error.

I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association’s rules. For further information on these rules, please contact your financial institution.

Authorized Signature Required:

Printed Name Required: Date Required:

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