Exhibit_G_Form_4109_Application_for_TIN.pdf

Form 4109 February 2022-E

Application for Texas Identification Number

Section I. Texas Identification Number (TIN) The number provided in this section will be used to report payments to the IRS, if applicable. A person or entity that has not received payment from Texas Health and Human Services Commission is a “new HHSC payee.” An answer of “Yes” requires completion of Sections I through VI.

An answer of “No” requires completion of Sections I, III, V and VI.

Indicate the type of number you are providing to be used for your TIN.

1 – Employer Identification No. (EIN) as assigned by IRS (9 digits, no dash)

Is this a new HHSC payee? (see specific instructions) Yes No Location/TIN Mail Code:

2 – Social Security No. or Individual Taxpayer Identification No (ITIN) (9 digits, no dashes)

3 – Current Texas Identification No. (11 digits)

Are you currently reporting any Texas tax other than unemployment (e.g., sales tax, franchise tax)? Yes No

If "Yes," enter the Texas Taxpayer No. (11 digits, no dashes):

Section II. Ownership Codes (To be completed for new HHSC payees only)

Check only one code by the appropriate ownership type that applies to you or your business and enter any required additional information.

I – Individual Recipient (not owning a business)

E – State Employee

Employing Agency No.:

S – Sole Ownership of Business (If checked, enter the following below:)

Owner's Name:

Social Security No.:

P – Partnership (If checked, enter two partner's names and SSNs. If a partner is a corporation, use the corporation's name and EIN)

Name:

SSN/EIN:

Name:

SSN/EIN:

L – Limited Partnership

Enter File No.

A – Professional Association

Enter File No.

C – Professional Corporation

Enter File No.

T – Texas Corporation: Profit Non-Profit

Enter File No.

O – Out-of-state Corporation Profit Non-Profit

R – Foreign (out of U.S.) W8 BEN is required Profit Non-Profit

G – Governmental Entity

U – State Agency/University

F – Financial Institution

N – Other (If checked, explain.) Profit Non-Profit

Section III. Payee Information Name of Payee – Individual or Legal Entity to be Paid (maximum 50 characters, including spaces)

DBA–Doing Business As, if applicable – Mailing address where you want to receive payments (maximum 35 characters per line)

DBA name or 1st line of address:

2nd line of address (if needed):

3rd line of address (if needed):

4th line of address (if needed):

Up to 4 lines including DBA name. This is the address where your payments will be sent.

City State ZIP Code Zone

Business/Daytime Area Code and Phone No. Payment Type PDT SIC Code Security Type (0, 1, 2) Vendor Type

Form 4109 Page 2 / 02-2022-E

Section IV. Payee Assignment Information An assignment is a legal transfer of a right or property. For the purposes of this form, it is the transfer of the right to payment. A copy of the assignment agreement signed by both parties must be attached.

Assignee Name Assignee SSN/EIN Date

Section V. Applicant Information Name of Applicant or Authorized Contact (please print) Area Code and Phone No. Date

Section VI. HHSC Representative Information (Required) Name of HHSC Representative and Division/Facility (please print) Area Code and Phone No. Date

Who Must Submit This Application This application must be submitted by every person (sole owner, individual recipient, corporation or other organization) who intends to bill or receive payment from the Texas Health and Human Services Commission for goods, services provided, refunds, public assistance, etc. Your Texas Identification Number (TIN) will be required on all vouchers submitted by any state agency. Your use of this TIN on all billings will reduce the time required to process your billings to the state of Texas.

General Instructions

• An HHSC representative may complete the form for the payee.

• Payees submit the form to their contract manager or HHSC representative responsible for their billings/invoices.

• The HHSC representative reviews the form for completeness prior to submitting to Accounting, Mail Code E-411.

• Do not use dashes when entering Social Security No., Employer Identification No. or Comptroller's assigned number.

• Disclosure of your Social Security No. is required if you are an individual or sole ownership. This disclosure requirement has been adopted under the Federal Privacy Act of 1974 (5 U.S.C.A. Section 552a(note)(West 1977), the Tax Reform Act of 1976 (42 U.S.C.A. Section 405(c)(2)(c) (West 1992), and Texas Government Code Section 403.055 (Vernon Supp. 1992). Your Social Security No. will be used to help the Comptroller of Public Accounts administer the state's tax laws and for other purposes. See Op Texas Attorney General No. H-1255(1978).

• Be advised that incomplete or incorrect information may cause delays in processing this application.

Specific Instructions

• Section I: The HHSC representative may enter the TIN location/Mail Code (last 3 digits of the TIN) to be set up, if known.

• Section II: This section is not required for current HHSC payees who are adding additional payment locations, unless there has been a change in ownership information.

Section 1, Texas Identification Number (TIN) EIN: For all ownership codes other than the individual listed in Section 3, enter a 9-digit Employer Identification Number (EIN) issued by the Internal

Revenue Service.

SSN: For the individual or sole owner without an EIN, enter your 9-digit Social Security number (SSN) issued by the Social Security Administration.

ITIN: For the individual or sole owner without an EIN, enter your 9-digit Individual Taxpayer Identification Number (ITIN) issued by the IRS.

Are you currently reporting any Texas tax to the Comptroller's office such as sales tax or franchise tax? If "Yes," enter Texas Taxpayer.

Section 2, Ownership Codes

• Check the box next to the appropriate ownership code and enter additional information as requested. Check only one box in this section. The Secretary of State's office may be contacted at 512-463-5555 for information regarding Texas file numbers.

Section 3, Payee Information

• Enter the complete name and mailing address where you want payments to be received. Names of individuals must be entered first name first.

Each line cannot exceed 50 characters, including spaces. If the name is more than 50 characters, continue the name on the next line down and begin the address in the next line down. City, state and ZIP code are required. Payee phone number is optional.

Section 4, Payment Assignment Information Use when one payee is assigning payment to another payee. When setting up an assignment payment, fill out this section completely and include a copy of the assignment agreement between the assignee and the assignor.

For assistance in completing this application, call HHSC Accounting at 737-867-7580.

With a few exceptions, you have the right to request and be informed about the information that the Health and Human Services Commission (HHSC) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask HHSC to correct information that is determined to be incorrect. (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, contact your local contract manager, caseworker or HHSC representative.