ESBD_526276_1781206317748_Form 5-Substitute W9.pdf

Form 6 Page 1 of 6

Texas Workforce Commission Instructions for TWC Substitute W-9 and Direct Deposit Form

Box # Instructions

Box 1 Legal Name: Legal business name filed with the IRS (as shown on tax return). For Sole Owner, enter the name of the owner.

Box 2 DBA or Assumed Name: Input additional business name if entity is also operating under a name other than the Legal Name input in Box 1.

Box 3 Tax Information Mailing Address: Address where IRS tax information is mailed.

(i.e., 1099 form, etc.).

Box 4 Payment Address: Address where payment is mailed, if different from address in Box 3.

Box 5 Taxpayer Identification Number: Either “SSN” or “EIN” must be selected, and the 9-digit SSN or EIN must be input. - This must be the number used for filing of tax return. (Select only one).

Box 6 Ownership Type: Select the most appropriate ownership type. (One ownership type must be selected). (see Note 4 below for additional guidance)

Box 7 Profit Status: Select the profit status of the business. (One status must be selected).

Box 8 Corporation Info: If ownership type selected in Box 6 is “T”, “A”, “L” or “C” and state of jurisdiction is “Texas”

- Then the File or Charter Number must be completed.

- (see Note 1 below)

Box 9 Sole Ownership Info: If ownership type selected in Box 6 is “S”

- Then the sole owner’s name and SSN must be completed.

Box 10 General Partnership Info: If ownership type selected in Box 6 is “P”

- Then the partner’s name and SSN/EIN must be completed. The information must be provided for two of the entity’s partners. Cannot be a duplicate of the EIN in Box 5.

- (see Note 2 below)

Box 11 Exemption from Backup Withholding: Do not enter information in this field unless you are exempt from Backup Withholding per the IRS requirements. To claim exemption, enter the applicable exempt payee code 1 through 13. (see Note 5 below for listing of IRS Exempt Payee Codes)

Box 12 Payment Distribution: Select the most appropriate payment distribution instructions. (One box for the payment distribution must be selected). For Direct Deposit, input name and address of financial institution, financial institution’s routing number (9 digits), bank account number, and type of account.

Box 13 Existing Account Information: (Complete ONLY if changing existing direct deposit information). When requesting a change to existing direct deposit account information, the existing account information is required for verification purposes.

Box 14 Either “Yes” or “No” must be selected if any of the three Direct Deposit statements were checked in Box 12:

“I am currently on Direct Deposit and wish to continue.”

“New Set-up” “Change in Direct Deposit Information”

- (see Note 3 below)

Box 15 Authorized signature must be completed. (Must be a physical signature).

Printed name and date must be completed.

Form 6 Page 2 of 6

Note 1: Texas based entities doing business as a:

- Texas Corporation (T)

- Professional Association (A)

- Texas Limited Partnership (L) - (this is a specific entity type, and is different from a general partnership)

- Professional Corporation (C)

Must have a Texas File Number/Texas Charter Number that is assigned by the Texas Secretary of State.

Questions related to this number should be directed to the Secretary of State’s office at (512)463-5555.

Note 2: A partnership must have a minimum of two partners but may have more. The name and SSN/EIN must be provided for two partners. The information related to the remaining partners is not required to be submitted.

Note 3: Federal requirement of the Office of Foreign Assets Control (OFAC), and per rules adopted by the National Automated Clearing House Association (NACHA).

Note 4: Ownership Types

Type Title Description S Sole Ownership Person with exclusive title or rights to a business.

P

Partnership Includes:

- Business General Partnership

- Individual General Partnership

Legal relationship that exists between two or more persons or other legal entities contractually associated as joint principals in a business.

L

Texas Limited Partnership

Partnership formed by two or more persons and having one or more general partners and one or more limited partners registered with the Texas Secretary of State.

T

Texas Corporation Includes:

- Limited Liability Corporation - Texas

- Texas Domestic Non-Profit

Corporation

- Texas Domestic Profit Corporation

Corporation registered with the Texas Secretary of State - -either profit or non-profit.

O

Out-of-State Corporation (Not Texas) Includes:

- Limited Liability Corporation - Out-of-State

Corporation legally chartered by a governmental entity outside the state of Texas.

G

Governmental Entity

Any legal government agency not created by the Texas Legislature, such as a city, county, or federal agency.

A

Professional Association

Entity is registered with the Texas Secretary of State as a Professional Association.

C

Professional Corporation

Corporation is registered with the Texas Secretary of State as a Professional Corporation.

I

Individual Recipient

An individual entitled to receive state payments such as a grant or state refund, who is not a sole proprietor (sole ownership).

F

Financial Institution

Any state bank, federal bank, savings and loan or credit union within the state of Texas or the United States.

R Foreign Corporation An entity outside the United States that may not have an EIN.

Form 6 Page 3 of 6

U

State Agency/University

Any Texas state agency or institution of higher education created by the Texas Legislature.

E

State Employee

Employee of a Texas state agency or institution of higher education.

N

Other

Organizations not defined within one of the other ownership types.

Note 5: IRS Exempt Payee Codes

IRS Payee Exempt

Code

IRS Description

An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2 The United States or any of its agencies or instrumentalities

A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions, agencies, or instrumentalities

4 A foreign government or any of its political subdivisions, agencies, or instrumentalities 5 A corporation

A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U. S. commonwealth or possession

7 A futures commission merchant registered with the Commodity Futures Trading Commission 8 A real estate investment trust 9 An entity registered at all times during the tax year under the investment Company Act of 1940

10 A common trust fund operated by a bank under section 584(a) 11 A financial institution 12 A middleman known in the investment community as a nominee or custodian 13 A trust exempt from tax under section 664 or described in section 4947

Form 6 Page 4 of 6

TWC Substitute W-9 and Direct Deposit Form

Box 1

Box 2

Box 3

Legal Name (as shown on your tax return):

Business Name - DBA (if different from Box 1):

Tax Information Mailing Address:

City: State: Zip:

Phone: Extension: Email:

Box 4 Payment Address (if different from Tax Address):

City: State: Zip:

Phone: Extension: Email:

Box 5

Box 6

Box 7

Box 8

Box 9

Box 10

Taxpayer Identification Number:

Note: Enter the same number used to file your tax return Social Security Number (SSN) Employer Identification Number (EIN)

Ownership Type: T=Texas Corporation (including Texas LLC) C=Professional Corporation (PC) O=Out-of-State Corporation (including Out-of-State LLC) A=Professional Association I=Individual Recipient L=Limited Partnership F=Financial Institution P=General Partnership R=Foreign Corporation S=Sole Owner U=State Agency/University G=Government Entity E=State Employee

N= Other If Other, please explain:

Profit Status: Profit Non-Profit

Corporation Info: State of Jurisdiction: File or Charter Number:

Sole Ownership Info: Sole Owner Name:

Sole Owner SSN:

General Partnership Information:

Partner 1 Name:

Partner 1 SSN/EIN:

Partner 2 Name:

Partner 2 SSN/EIN:

Form 6 Page 5 of 6

Box 11

Backup Withholding:

Please see IRS website for requirements.

Do not enter information in this field unless you are exempt from Backup Withholding, per the IRS requirements. To claim exemption, enter the applicable exempt payee code 1 through 13.

Form 6 Page 6 of 6

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 at 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 when changing existing direct deposit information) Financial Institution Routing Number: Type of Account:

Account Number: Checking Savings Box 14

Box 15

International Payment Verification (Required)

Will payments be forwarded to a financial institution outside the United States? Yes No If “YES”, also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).

Certification and Authorization of TWC Substitute W-9 and Direct Deposit Form (Required) Authorization for Direct Deposit Setup, Changes or Cancellations:

I authorize the state agency that issues my state of Texas payments via the Texas Comptroller of Public Accounts to electronically deposit my payments to my financial institution. I understand that any payments deposited in error to my account will be reversed by the agency that issues my state of Texas payments via the Texas Comptroller of Public Accounts.

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

Per IRS requirements:

Under penalties of perjury, I certify that:

1) I have provided my correct taxpayer identification number,

2) I am not subject to backup withholding due to failure to report interest and dividend income,

3) I am a US citizen or other US person,

4) Note: Certification of the accuracy of the FATCA code entered on this form is not applicable since FATCA code is not captured on this form.)

The Internal revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Authorized Signature (Required):

Printed Name (Required): Date (Required):

Texas Workforce Commission