ESBD_473126_1764688045963_05_ Form 4 Substitute W-9 and Direct Deposit Form.pdf

DARS1020INST (06/17) Page 1 of 1

Texas Workforce Commission Vocational Rehabilitation Services

TWC Substitute W-9 and Direct Deposit Form Instructions

Box Number

Instruction

Legal Name: Legal business name filed with the IRS (as shown on your income tax return). For sole ownership, excluding LLC, enter the name of the owner.

DBA: Name you are "Doing Business As" if different from legal business name (business name, disregarded entity name.)

Tax Information Mailing Address: Address where IRS tax information is sent. (i.e. W9, 1099, etc.)

4 Payment Address: Remit Address for payments if different from the address in Box 3.

Taxpayer Identification Number: Select the appropriate check box for the taxpayer identification number you are entering. Enter only one number.

Federal Tax Classification: Select only one that describes the ownership type of business.

7 Profit Status: Select only one that describes the profit status of the business.

Corporation Information: The state where corporation status is filed and the file or charter number of corporation in that state.

Sole Ownership Info: Name and Social Security Number of sole owner (excluding LLC) if using an Employer Identification Number (EIN).

General Partnership Information: Name and Social Security Number or EIN of all partners involved in the general partnership. Please attach additional sheet if needed.

Exemption from Backup Withholding: Check this box if the business is exempt from backup withholding. For further information on backup withholding, see the following IRS website: www.irs.gov/pub/irs-pdf/fw9.pdf

New Account Information (Setups and Changes): Please check the box that is appropriate for this Direct Deposit request. Enter name of financial institution. Check the appropriate box for type of account. Enter the financial institution’s routing transit number (9 digits) from the deposit slip for the financial institution listed. Enter the bank account number.

Existing Account Information (Complete only for direct deposit information change): When requesting a change to your existing direct deposit account information, you must complete box 13 with the existing account information for verification purposes.

This measure will help the Texas Workforce Commission verify accuracy of the requested change.

International Payments Verification: Check "YES" or "NO" to indicate if direct deposit payments to the account information designated in Box 12 of this form will be forwarded to a financial institution outside the United States.

Certification instructions: You must cross out item 2 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. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you must provide your correct TIN. THIS BOX MUST BE SIGNED AND DATED. For more information go to IRS website at: http://www.irs.gov/pub/irs-pdf/fw9.pdf?portlet=3 http://www.irs.gov/pub/irs-pdf/fw9.pdf http://www.irs.gov/pub/irs-pdf/fw9.pdf?portlet=3

Note: Enter the same number used filing your tax return

TWC Substitute W-9 and Direct Deposit Form

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

Box 2

Box 3

Box 4

Business Name (if different from Box 1):

Tax Information Mailing Address:

City: State: Zip:

Phone: Fax: Email:

Payment Address (if different from Tax Address):

City: State: Zip:

Phone: Fax: Email:

Social Security Number (SSN) Employer Identification Number (EIN)

T=Texas Corporation; C=Professional Corporation; or T/O= Limited Liability Company

A=Professional Assoc.

L=Limited Partnership P=General Partnership O=Out-of-State Corporation S=Sole Owner G=Government Entity

Profit Non-Profit

Sole Owner Name:

Sole Owner SSN:

Partner 1 Name:

Partner 1 SSN/EIN:

Partner 2 Name:

Partner 2 SSN/EIN:

Exempt from Backup Withholding

Box 5

Box 6 Federal Tax Classification/ Business Designation:

Box 7 Profit Status:

Box 8 Corporation Info:

Box 9 Sole Ownership Info:

Box 10 General Partnership Information:

Box 11 Backup Withholding:

Please see IRS Website

Taxpayer Identification Number:

I=Individual Recipient F=Financial Institution R=Foreign Corporation U=State Agency/University E=State Employee N= Other

If Other, please explain:

State of Jurisdiction: File or Charter Number:

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Direct Deposit Information (Response Required) Box 12 New Account Information (Setups and Changes)

I am currently on Direct Deposit and wish to continue. I decline Direct Deposit a t this time.

New Set-up Change in Direct Deposit Information Cancel My Direct Deposit

Financial Institution Name:

Financial Institution Address: City: State: Zip:

Financial Institution Routing Number: Type of Account:

Account Number: Checking Savings Box 13 Existing Account Information (Complete only for direct deposit information change)

Financial Institution Routing Number: Type of Account:

Account Number: Checking Savings Box 14 Will payments be forwarded to a financial institution outside the United States? Yes No Box 15 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 R e qui r ed:

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