W-9 Blank.pdf

Form W-9 (Rev. October 2004) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester. Do not send to the IRS.

Name (as reported on your income tax return)

Business Name, if different from above

Check appropriate box: □ Individual/ Sole proprietor □ Corporation □ Partnership □ Other ► _ _ _ _ _ _ _ _ _ _ □ Exempt from backup withholding

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Requester’s name and address (optional)

Pr in t o r t yp e

S ee

S pe ci fic

In st ru ct io ns o n pa ge

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social security number or Employer identification number

Part II Certification 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. person (including a U.S. resident alien).

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 individual 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. (See the instructions on page 4.)

Sign Here

Signature of U.S. person ► Date ►

By signing above, I understand that any person who misrepresents a firm’s status as a small, HUBZone small, small disadvantaged, women-owned or Veteran or Service-Disabled Veteran-Owned Small Business concern in order to obtain a contract awarded under the Small Business Act shall 1) be punished by imposition of fine, imprisonment or both, 2) be subject to administrative remedies including suspension and debarment, and 3) be ineligible for participation in programs conducted under the Authority of the Act.

Required Federal Business Classification Information

Large Business Concern: Dominant in field of operations per Federal Acquisitions Circular (FAC 9.201) (LBC) Y ____ N ____

Small Business Concern: Independently owned and operated, and meets industry size and receipt (SBC) Y ____ N ____ requirements for small businesses per SBA13 CFR 121, Section 3 of the Small Business Act.

Woman-Owned Small Business: Is a small business and at least 51% owned and controlled by one or (WOSB) Y ____ N ____ more women who are U.S. citizens and have active involvement in day-to-day operations.

Small Disadvantaged Business: SBA certified; minimum 51% owned, controlled and operated day-to-day (SDB) Y ____ N ____ by one or more socially and economically disadvantaged individuals.*

Historically Black Colleges/Universities and Minority Institutions: (HBCU/MI) Y ____ N ____

HUB Zone Small Business: SBA certified; is small and is located in an ‘historically underutilized business (HUB Zone Y ____ N ____ zone” and is owned and controlled by one or more US citizen(s) and at least 35% of employees reside in SB) HUB zone.

Veteran-Owned Small Business: Is a small business and is at least 51% owned, controlled and has active (VOSB) Y ____ N ____ involvement in day-to-day operations by one or more U.S. veterans.

Service-Disabled Veteran-Owned Small Business: VOSB and with a disability that is service connected; (SDVOSB) Y ____ N ____ may include spouse/caregiver of veteran with permanent or severe disabilities.

*SDB Ethnicity Definitions (Please check one): African American____; Hispanic American____;

Native American (American Indian, Eskimo, Aleut & Native Hawaiian)____; Asian-Pacific American____; Asian-Indian American____.

Arapahoe Community College 5900 S. Santa Fe Drive Littleton, CO 80160-9002