Free 23743.pdf - Indiana

Subsititute Form Taxpayer Identification Number Request State Form 23743 (R 07\01) Approved by State Board of Accounts 2001 Approved by Auditor of State 2001

State of Indiana

W-9
Print or Type Legal Name
(OWNER OF THE EIN OR SSN AS NAME APPEARS ON IRS OR SSN RECORDS)

DO NOT send to IRS

Return to address below

DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE

Trade Name

Complete only if doing business as (D/B/A)

Remit Address Purchase Order Address-Optional

Check legal entity type and enter 9 digit taxpayer identification Number (TIN) below: (SSN = Social Security Number, EIN = Employer Identification Number) Individual
Sole Proprietorship (Owner's SSN or Business EIN)
(Individual's SSN) SSN EIN

SSN or EIN must be for legal name above

__ __ __-__ __-__ __ __ __ __ __ __-__ __-__ __ __ __ __ __-__ __ __ __ __ __ __ __ __-__ __ __ __ __ __ __ __ __-__ __ __ __ __ __ __

Partnership Estate/Trust

General

Limited

(Partnership's EIN) (Legal Entity's EIN)

Note: Show the name and number of legal trust, or estate, not personal representatives

Other Corporation

(Limited Liability Company, Joint Venture, Club, ect) Do you provide legal or medical serv. Yes

(Legal Entity's EIN) No (Corp's EIN)

__ __-__ __ __ __ __ __ __ __ __-__ __ __ __ __ __ __ __ __- __ __ __ __ __ __ __

Governement (or Government operated entity) Organization Exempt from Tax under Section 501(a)
Do you provide medical services? Yes

(Entity's EIN)

No

(Org's EIN)

__ __-__ __ __ __ __ __ __

Check here if you do not have a SSN or EIN but have applied for one.
Under Penalties of prejury, I certify that: (1) The number listed 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 the 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 (does not apply to real estate transactions, mortgage interest paid, and acquisition or abandonment of secured property, contribution to an indivual retirement arrangement (IRA), and payments other than interest and dividends.) 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 of underreporting interest or dividends on your tax return.

THE IRS DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.

I am a U.S. person (including a U.S. resident alien)
Name (Print or Type) AUTHORIZED SIGNATURE Title Date Phone

Agency

Agency use only

Yes

No Approved by

1099 REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

Purpose of form: We are required to file an information return with the IRS and must get your correct taypayer identification number (TIN) to report our payments to you. Use Form W-9 on the reverse side, if you are a U.S. person (including a U.S. resident alien), to give us your correct TIN and, when applicable to: 1. Certify the TIN you are giving is correct. 2. Certify you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are an exempt payee. If you do not provide us with the information, your payments may be subject to 31% federal income tax backup withholding. Also, if you do not provide us with information, you may be subject to a $50.00 penalty imposed by the Internal Revenue Service per I.R.C. 6723. Federal law on backup withholding preempts any state and local law remedies, such as any rights to a mechanic's lien. If you do not furnish a valid TIN, or if you are subject to backup withholding, the payer is required to withhold 31% of its payment to you. Backup withholding is not a failure to pay you. It is advance tax payment. You should report all backup withholding as a credit for taxes on your federal income tax return. Specific Instrustions: Enter your legal name on that line. Your legal name is the one that appears on your Social Security Card or Employer Identification Number if a business. If you are a sole proprietor, then your legal name is the business owner's name. If you have a "doing business as" (d/b/a) name, enter on the trade line. Enter your remit address on the next line, and if you have a separate address for purchase orders, enter that address on the appropriate line. Next, select the organization type for your name, check the box, and record the appropriate taxpayer identification number (TIN) in the space provided. Notice that individuals and sole proprietors are the only types with a social security number. If you are a corporation or an exempt 501(a) organization, you must answer yes or no on legal and medical services. If you are sole proprietor you must show the business owner's name in the legal box, and the business name in the trade name bo You cannot use only the business name. For the TIN, you may use either the individual's SSN or the employer identification number (EIN) of the business. However, the IRS prefers that you show the SSN. Finally, complete the certification section, sign and date the form. If you are a foreign person, use the appropriate From W-8.