Exhibit B-W-9 Form.pdf
PDF 157 KB Posted
- Solicitation number
- 25RFP18004
- Issued by
- Minnehaha County, South Dakota
About this file
This document is a Substitute W-9 Taxpayer Identification Number (TIN) Verification form issued by the State of South Dakota, Bureau of Finance and Management (BFM). The form is designed to be submitted to the state agency from which the vendor receives invoices, not to the Internal Revenue Service, and serves as a prerequisite for doing business with South Dakota state agencies. Vendors are required to provide their legal name, business name or doing-business-as designation, taxpayer identification number, and entity designation selected from categories including individual/sole proprietor, partnership, corporation, limited liability company, governmental entity, trust/estate, or other entity types. The form requires specification of order and remit addresses where purchase orders and payment checks should be directed, and vendors must certify under penalty of perjury that the provided taxpayer identification number is correct, that they are not subject to backup withholding, and that they are a U.S. person or resident alien.
The form includes optional direct deposit information allowing vendors to provide banking details for electronic payment processing, including bank account number, routing number, and account holder name. Vendors are required to provide a legible email address to receive electronic notification of payment issuance and access to the SD Vendor Self Service website. Upon completion by the vendor, the form must be processed by the state agency, which assigns a vendor number for new vendors added to the South Dakota Accounting System (SDAS). This vendor number is mandatory for any new vendors entering the state procurement system and is recorded by the receiving agency along with the agency contact name, date received, and associated contact information.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
State of South Dakota
BFM-0001 (V03/201907)
Substitute W-9
SEND TO THE STATE AGENCY
YOU SEND INVOICES
DO NOT send to IRS
Taxpayer Identification Number (TIN) Verification Print or Type Please see attachment or reverse for complete instructions.
This form can be made available in alternative formats to qualified individuals upon request.
Legal Name (as entered with IRS) If Sole Proprietorship enter your Last, First MI
Entity Designation (check only one) Required
Individual / Sole Proprietor Partnership C Corporation S Corporation Limited Liability Company - Individual Limited Liability Company - Partnership Limited Liability Company - Corporation Governmental Entity Hospital Exempt from Tax or Government Owned
Long Term Care Facility Exempt from Tax or Government Owned
Trust/Estate All Other Entities (specify e.g. 501(c)(3), etc.)
Taxpayer Identification Number (TIN)
Business Name If doing business as (DBA) or enter business name of Sole Proprietorship
Order Address (where order should be mailed) PO Box or Number and Street, City, State, ZIP + 4
Remit Address (where check should be mailed) PO Box or number and street, City, State, ZIP + 4
Exemptions Check Only One Required
Social Security Number (SSN) Employer Identification Number (EIN) Individual Taxpayer Identification Number for U.S. Resident Aliens (ITIN)
Exempt payee code (if any):
Exemption from FATCA reporting code (if any):
Certification Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, AND
2. I am not subject to back up withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to back up 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.
3. I am a U.S. person (including a US resident alien).
Printed Name Printed Title Telephone Number
Signature Date (mm/dd/yy)
Optional Direct Deposit Information Your Bank Account Number Checking
Savings Bank Routing Number (9-digit ABA #) Name on Bank Account
THIS IS A:
new direct deposit change of existing (providing old banking information required to change existing)
Old Bank Account Number Old Routing Number (9-digit ABA #) You must provide the previous banking information to make a change.
Required e-mail address (Please make this LEGIBLE)
If you provide an email address you will be sent electronic notification when a payment is issued. You will also receive a PIN for use when logging into the SD Vendor Self Service website at http://bfm.sd.gov/vendor. We will NOT share your email address with anyone or use it for any purpose other than communicating remittance information.
Information below to be completed by the State Agency. Vendor Number required for any new vendors added to SDAS.
State Agency: Agency Contact: Date: Vendor Number assigned by SDAS:
| Business Name If doing business as DBA or enter business name of Sole Proprietorship: |
| Individual Sole Proprietor: Off |
| Partnership: Off |
| C Corporation: Off |
| S Corporation: Off |
| Limited Liability Company Individual: Off |
| Limited Liability Company Partnership: Off |
| Limited Liability Company Corporation: Off |
| Governmental Entity: Off |
| Hospital Exempt from Tax or Government: Off |
| Long Term Care Facility Exempt from Tax or: Off |
| TrustEstate: Off |
| All Other Entities specify eg 501c3 etc: Off |
| Social Security Number SSN: Off |
| Employer Identification Number EIN: Off |
| Individual Taxpayer Identification Number: Off |
| Printed Name: |
| Printed Title: |
| Telephone Number: |
| Date mmddyy: |
| Checking: Off |
| Savings: Off |
| Name on Bank Account: |
| new direct deposit: Off |
| change of existing providing old banking information required to change existing: Off |
| Old Bank Account Number: |
| Exempt Payee code (if any): |
| FATCA reporting code (if any): |
| Bank Account Number: |
| Bank Routing Number: |
| Old Routing Number: |
| e-mail address: |
| Legal Name as entered with IRS: |
| Order Address where order should be mailed: |
| Remit Address where check should be mailed: |
| Text5: |
| Text6: |
| Text1: |
| Text2: |
| Text3: |
| Text4: |
| Text9: |
| Text8: |
| Text10: |
File details come from the government source that posted it. Updated .