W-9_Substitute_Form_081423.pdf

Accounts Payable Department Attn: Vendor Registration PO Box 3408 Tampa, FL 33601 813-272-4931

DO NOT SEND TO THE IRS

SUBSTITUTE W-9 VENDOR PAYMENT PROFILE FORM

Email completed form to VendorRegistration@hcps.net

To conform to IRS regulations for Form 1099 reporting, we must have a Federal Tax Identification Number or Social Security Number in our files for ALL VENDORS and INDIVIDUALS receiving payments from Hillsborough County Public Schools; therefore, we request that you provide the following information. Notwithstanding, all inquiries regarding Ethnicity, Race, Gender or Business Certification/Designation are of a purely voluntary nature. If you have any questions regarding the completion of this form, please contact the procurement department at the address above.

New Requ est

Change Name Tax ID Remit Address Other

Legal Name of Business or Individual (as shown on your Income Tax Return)

If Doing Business As, DBA Name (use if doing business as (DBA) or enter business name of Sole Proprietorship)

Primary Address PO Box or Number and Street, City, State, Zip + 4

Remit To Address (if different from above) PO Box or Number and Street, City, State, Zip + 4

Contact Name, Phone, Email, Fax Number

Taxpayer Identification Number (TIN) Provide Only One

(If sole proprietorship provide EIN, if applicable)

Social Security Number (SSN) Employer Identification Number (EIN)

NOTE: Our standard payment terms are 45 days net.

Would you like to discuss “pay upon approval” terms? Yes No

Accepted Payment Types Check Visa ACH

Certification

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

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 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 a U.S. resident alien), AND

4. The FATCA code(s) entered on this form (if any) indicating I am exempt from FATCA reporting is correct.

Entity Designation (check only one type)

Individual / Sole Proprietor

Partnership

C Corporation

S Corporation

Limited Liability Company – Individual

Limited Liability Company – Partnership

Limited Liability Company – Corporation

Government Entity

Estate / Trust

Organization Exempt from Tax – Nonprofit (under

Section 501 (a)(b)(c)(d))

Exemption (See Instructions)

Exempt payee code (if any)

Exemption from FATCA Reporting Code (if any)

Services Provided

Medical Legal

Hillsborough County Public Schools is committed to doing business with contractors, vendors and other suppliers who reflect the great diversity of our community. We encourage

Small Business Enterprises to register with our Office of

Supplier Diversity, (813) 635-1240. Please complete the following information:

Service-Disabled Veteran YesV NoN

Small/Small Local Business Enterprise YesO

NoN

Minority Classification African AmericanA

Asian AmericanS

Caucasian FemaleC

Hispanic AmericanH

Native AmericanI

Majority Owner’s Gender FemaleF MaleM

Certified/Registered Agency (select most recent approval)

City of TampaT

FSMSDCF (Florida State National Minority Supplier

Development Council)

Hillsborough CountyH

State of Florida S

WBENCW (Women’s Business Enterprise National Council)

OtherO

Printed Name Printed Title Telephone Number

Signature Date Email Address mailto:VendorRegistration@sdhc.us

Instructions for Completing Taxpayer Identification Number (TIN) Verification (Substitute W-9)

Legal Name As registered with the Internal Revenue Service (IRS)

• Individuals: Enter First Name MI Last Name

• Sole Proprietorships: Enter First Name MI Last Name

• LLC Single Owner: Enter owner’s First Name MI Last Name

• All Others: Enter Legal Name of Business

Request Type Indicate if this is a new request or a change to a previous form. If a change, indicate information to be updated.

Entity Designation Check ONE box which describes the type of business entity.

Exemption See page 3.

Business Name

• Individuals: Leave blank

• Sole Proprietorships: Enter Business Name

• LLC Single Owner: Enter LLC Business Name

• All Others: Complete only if doing business as a DBA

Services Provided Indicate if you provide medical or legal services

Ethnicity Codes Indicate the ethnicity of the owner and indicate whether female or male.

Business Certification/Designation Indicate the business certification or designation, if applicable.

Primary Address Address where purchase orders should be mailed.

Certification You must cross out item 2 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.

Remittance/Accounts Receivable Information Address where payments and 1099 tax form should be mailed. Complete only if different from primary address.

Contact Name, Phone, Email Information for accounts receivable contact.

Taxpayer Identification Number LIST ONLY ONE: Social Security Number OR Employer Identification Number.

See “Legal Name and Tax Payer ID" below.

If you do not have a TIN, apply for one immediately. Individuals use federal form SS-05 which can be obtained from the Social Security Administration. Businesses and all other entities use federal form SS-04 which can be obtained from the Internal Revenue Service.

Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to furnish your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, or contributions you made to an IRA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. You must provide your TIN whether or not you are required to file a tax return.

Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not furnish a TIN to a payer. Certain penalties may also apply.

Payment Terms We offer pay upon approval terms for participation in our SBE program, e-payments, and some term discounts.

Accepted Payment Types Indicate all payment types accepted for invoice payments.

Registration with Office of Supplier Diversity Indicate if you are registered with the Schools District’s Office of Supplier Diversity program.

Legal Name and Tax Payer ID For this type of account: Give name and SSN of: For this type of account: Give name and EIN of:

Individual The individual Sole Proprietorship or Single- Owner LLC The owner 3

Two or more individuals (joint account) The actual owner of the account or, if combined funds, the first individual on the account 1

A valid trust, estate, or pension trust Legal entity 4

Custodian account of a minor (Uniform Gift to Minors Act) The minor 2 Corporation or LLC electing corporate status on Form 8832 The corporation

Custodian account of a minor (Uniform Gift to Minors Act) The minor 2

Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

The usual revocable savings trust (grantor is also trustee) The grantor-trustee 1 Partnership or multi-member

LLC The partnership

So-called trust account that is not a legal or valid trust under state law The actual owner 1 A broker or registered nominee The broker or nominee

Sole proprietorship or Single- Owner LLC The owner 1

Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district or prison) that receives agricultural program payments

The public entity

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name, but you may also enter your business or “DBA” name. You may use either your SSN or EIN (if you have one).

4 List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Instructions for Completing Taxpayer Identification Number (TIN) Verification (Substitute W-9)

Exemptions If you are exempt from backup withholding and/or Foreign Account Tax Compliance Act (FATCA) reporting, enter in the Exemptions box any code(s) that may apply to you. See Exempt payee code and Exemption from FATCA reporting code below.

Exempt payee code Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Corporations are not exempt from backup with- holding for payments made in settlement of payment card or third party network transactions.

Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.

The following codes identify payees that are exempt from backup withholding:

1. 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

3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities

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

5. A corporation

6. A dealer in securities or commodities required to register in the United

States, the District of Columbia, or a possession of the United States

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 lnvestment

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

Exemption from FATCA reporting code The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements.

A. An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B. The United States or any of its agencies or instrumentalities C A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities D. A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472-1(c)(1)(i) E. A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i) F. A dealer in securities, commodities, or derivative financial instruments

(including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G. A real estate investment trust H. A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the lnvestment Company Act of 1940

I. A common trust fund as defined in section 584(a) J. A bank as defined in section 581 K. A broker L. A trust exempt from tax under section 664 or described in section

4947(a)(1) M. A tax exempt trust under a section 403(b) plan or section 457(g) plan