ESBD_520882_1779974056182_Form 02-W-9 and Direct Deposit Form (VR1020).pdf

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:

TWC1020 (06/18) Page 1 of 2

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:

TWC1020 (06/18) Page 2 of 2

TWC Substitute W-9 and Direct Deposit Form