Substitute W-9 - City of Galax.pdf
PDF 260 KB Posted
- Attached to
- Surfacing and Setting of Poles/Nets
- Solicitation number
- 70474
- Issued by
- Goochland County, Virginia
About this file
This document is a Substitute W-9 form for the City of Galax, Virginia. It is used to establish a vendor account with the City and provides the necessary certifications as required by the Internal Revenue Service. The form collects the vendor's legal name, Doing Business As (DBA) name, main address, remittance address, contact information, and taxpayer identification number (Social Security Number or Employer Identification Number). The vendor must certify under penalties of perjury that the information provided is correct and that they are a U.S. citizen or other U.S. person.
The related state and local contract opportunity is for the surfacing and setting of poles/nets for four new outdoor pickleball courts and one basketball court at Felts Park in Galax, Virginia. The City of Galax is seeking sealed bids from qualified contractors to complete this work. The Scope of Work and all attachments provide details on the project requirements. The City of Galax reserves the right to waive irregularities and reject any and all bids.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP 24-0009.pdf | ||
| BID FORMS 24-0009.pdf |
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| Title: City of Galax Vendor Authorization and Substitute W-9 Form |
| Return Form To: Return Completed Form To: |
| Purpose: To establish a vendor account with The City of Galax, all entities must complete this form and provide the necessary certifications as required by the Internal Revenue Service (IRS). The IRS requires entities to complete a substitute W-9 when requested if it is substantially similar to IRS's Form W-9. |
| Return Form To Add Text: City of Galax - Procurement |
111 E Grayson Street Galax, VA 24333 OR: email to
| Questions: For questions with this form please contact the Finance Office, Derek Spraker at 276-236-2131. |
| Upload link: dspraker@galaxva.com |
| Reset: |
| Do Not Send: DO NOT send to IRS |
| Entity Name Title: To avoid backup withholding, the legal name provided must match the legal name on file with the IRS for the tax identification number (TIN) provided below. If the account is in more than one name, list first the name of the person whose number matches the TIN provided. |
| Legal Name: Legal Name: |
| Legal Name Fillable: |
| DBA Name: Doing Business As (DBA): |
| DBA Fillable: |
| DBA Payable: Payments should be made payable to DBA |
| Main Address: Main Address (Where tax information and general correspondence is to be mailed) |
| Remitt Address Title: Remittance Address (Where payment is to be mailed) |
| Payable DBA Check Box: Off |
| Vendor identificaiton & tax header: Contact and Taxpayer Identification Information |
| M Address 1: Address Line 1: |
| M Address 1 Fillable: |
| M Address 2: Address Line 2: |
| M Address 2 Fillable: |
| M City: City: |
| City Fillable: |
| M State: State: |
| M State Fillable: |
| M Zip Code: Zip Code: |
| M Zip Code Fillable: |
| Remit address Same: Off |
| Same as Address Text: Same as Main |
| R Address 1: Address Line 1: |
| R Address 1 Fillable: |
| R Address 2: Address Line 2: |
| R Address 2 Fillable: |
| R City: City: |
| R City Fillable: |
| R State: State: |
| R State Fillable: |
| R Zip Code: Zip Code: |
| R Zip Code Fillable: |
| Contact Name: Contact Name: |
| Contact Name Fillable: |
| Contact Title: Title: |
| Contact Title Fillable: |
| Contact Phone Number: Contact Direct Phone: |
| Contact Phone Number Fillable: |
| Ext Fillable: |
| Contact Email:: Contact Email: |
| Email Fillable: |
| Main Phone Number: Main Phone Number: |
| Main Phone Number Fillable: |
| Ext:: Ext: |
| Ext Fillable2: |
| TIN Title: Taxpayer Identification Number (TIN) (Provide ONE Only) |
| Social Security #: Social Security Number: |
| SSN Fillable: |
| OR: OR |
| FEIN: Employer Indentification Number: |
| FEIN Fillable: |
| Exempt payee code: Exempt payee code (if any) |
| Exempt Payee Code Fillable: |
| Exemption FATCA Fillable: |
| Exemption: Exemptions - Applies to accounts maintained outside of the U.S. |
| Exemption from FATCA Reporting Code (if any): Exemption from FATCA reporting code (if any) |
| Instructions note: Please see IRS Form W-9 instructions for assistance. Instructions can be found at www.irs.gov/FormW9. |
| Entity Type: Off |
| Individual: Individual |
| Sole proprietorship: Sole proprietorship |
| Single Member LLC: Single member LLC |
| C Corporation: C Corporation |
| S Corporation: S Corporation |
| Partnership: Partnership |
| LLC - S Corporation: LLC - S Corporation |
| LLC - Partnership: LLC - Partnership |
| Entity Type Title: Business Type: |
| Entity Type comment: (Check only one of the following boxes) |
| Certification header: Certification |
| Certification Wording: Under penalties of perjury, I certify that: |
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup 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 backup 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; and
3. I am a U.S. citizen or other U.S. person (including U.S. resident alien); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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 indivdiual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. While IRS does not require signature for certain types of transactions, the City of Galax requires signature certifying the accuracy of the information submitted on this form.
| Printed Name: Printed Name: |
| Printed Name - Fillable: |
| Signing Title: Title: |
| title Fillable: |
| Date: Date: |
| Date Fillable: |
| Authorized Signature: Authorized Signature: |
| Signature Name - Fillable: |
| Internal Use: Internal Use Only: |
| Department Requesting: Department Requesting Vendor: |
| Dept Requesting Fillable: |
| Department Contact: Department Contact: |
| Dept Contact Fillable: |
| Printed Name Field: ______________________________________________________________________________________________________ |
| Signature Name Field: ______________________________________________________________________________________________________ |
| Trust or Estate: Trust or Estate |
| Government: Government |
| Non-profit: Non-profit |
| LLC - C Corporation: LLC - C Corporation |
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