REQUEST FOR TAXPAYER IDENTIFICATION AND CERTIFICATION
YOU RECEIVED THIS FORM because a state agency may make a payment to you for services, supplies, or as a reimbursement. YOU ARE REQUIRED BY IRS to provide complete and accurate tax identification information. W-9
READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM. Accurately completing this form will assist us in establishing your account for payment processing.
1. NAME & ADDRESS
2. BUSINESS NAME State Use Only 4. ORGANIZATION TYPE You Must Check One Only. Make sure that the V I O organization type corresponds to the tax identification __________________________________________ number. __________________________________________ 6 Y T ___ Single Owner LLC 7 Y I ___ Individual/Sole Proprietorship 1 N E Sole Proprietor: Enter your individual name as ___ State of Oregon Employee 5 Y P shown on your social security card in the Name & ___ Attorney-At-Law 5 N O Address box. You may enter your business, trade, or ___ Corporation, except Medical Corporations 5 Y N “doing business as (DBA)” name on the Business ___ Medical Corporation 5 Y N Name line. ___ Medical/Health Care, not Incorporated 5 N G ___ Non-Profit (copy of Exemption Notice required) 5 Y T ___ Partnership, LLC, LLP 7 Y T ___ Trust 3 N G ___ Government Agency 4 N G ___ Local Government/Political Subdivision 3. TAX IDENTIFICATION NUMBER (TIN) You must provide your TIN (SSN or EIN) whether or not you are required to file a tax return. Payers must generally withhold at the 5. To sign up for direct current IRS backup withholding rate for taxable interest, dividend, and certain other payments to a payee who does not give a TIN to The number shown on this form is my correct taxpayer deposit payment a payer. See back of form for applicable penalties and identification number, and service and receive instructions. I am a U.S. person (including a U.S. resident alien), and convenient, electronic payments, log-on to READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE RESPONDING TO THE NEXT ITEM http://egov.oregon Under penalties of perjury, I certify that I am not subject to backup withholding because: a) I am exempt from backup .gov/DAS/SCD/ withholding, or b) I have not been notified by the Internal SFMS/ach.shtml Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup on the internet. withholding. Click on Forms and Brochures. Then You must cross out the above paragraph if you have been select Direct If you do not have a TIN, write “Applied For” in the space for the notified by the IRS that you are currently subject to backup Deposit (ACH) TIN, sign and date the form and give it to the requestor. You will withholding because of underreporting interest or dividends Authorization Formbe subject to backup withholding on all 1099-MISC reportable on your tax return. payments until you provide your TIN to the requestor
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
6. AUTHORIZED SIGNATURE _________________________________________________________________
NAME (Print or Type) ____________________________________________________________________________________________
(If representing a business/organization)
WHY YOU RECEIVED THIS FORM: A State of Oregon agency has established an account for the named person or business. Payments may be
made for services, supplies, or as a reimbursement. All information supplied is confidential and will be for the purpose of reporting to IRS those payments already subject to such reporting requirements or may be disclosed to federal law enforcement and intelligence agencies to combat terrorism.
NAME & ADDRESS: Verify that the name and address on the form are correct. If not correct, draw a line through the incorrect information
and write the correct information to the side. If using a SSN the name must be written on the form exactly as it appears on your social security
card. If using a FEIN the name must be written on the form exactly as it appeared on Form SS-4, Application for Employer Identification Number. Enter your telephone and fax numbers, if incorrect or missing.
BUSINESS NAME: Enter any business, trade, or “doing business as (DBA)” name. The TIN, ORGANIZATION TYPE and NAME must all be
for the same entity.
TAX IDENTIFICATION NUMBER (TIN): Verify that the TIN is correct for the entity named on the form. This number can be either a
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) or SOCIAL SECURITY NUMBER (SSN). If the tax identification number
preprinted on the form is incorrect, draw a line through it and write in the correct number.
ORGANIZATION TYPE: The following definitions and type of number required may help identify the correct selection:
Single Owner LLC- Any business owned by a single member. Give name of the owner. The IRS prefers a SSN.
Individual - A private person. Give SSN of the individual.
Sole Proprietorship- Any business or venture owned by a single person. Give name of the owner. The IRS prefers a
State of Oregon Employee - An employee of the State of Oregon on the state payroll system. Give SSN of the individual.
Attorney-At-Law - Attorney-at-Law, either incorporated or non-incorporated. Give either SSN of the individual or FEIN of
Corporation Except Medical - Any corporation formed under the laws of any U.S. state or territory except for non-profit, governmental or
medical/health care corporations. Give FEIN of the organization.
Medical Corporation-INC Any corporation that provides a medical or health care service. Give FEIN of the organization.
Medical/Health Care – non INC Any business or venture that provides medical or health care services, but is not incorporated. Give
legal name and TIN of the organization or owner.
Non-Profit - Any non-profit organization formed under the laws of any U.S. state or territory. Give name and
FEIN of the organization. A copy of your EXEMPTION CERTIFICATE is required.
Partnership - Any business or venture owned by two or more partners. Includes LLP and LLC. Must have a
FEIN. If you are a single-member LLC enter the owner‟s name in the NAME & ADDRESS box. Enter the
LLC‟s name on the BUSINESS NAME line.
Government Agency - Any part of the government of the United States or of any state, or any political subdivision of a
state other than Oregon, or a foreign government. Give FEIN of the organization.
Local Government - Any local government agency or political subdivision of the State of Oregon. Include your political
Certification: IRS requires an individual or organization that is subject to backup withholding to have withholdings at a rate set by the IRS, from
any 1099-MISC reportable payment. The amount deducted is paid directly to IRS. Backup withholding is NOT a monthly or quarterly payroll tax withholding. You are subject to backup withholding if: 1) you have received a special notice telling you so, or 2) you failed to provide a correct Taxpayer ID Number (TIN) as requested, or 3) you failed to report interest or dividend income. Sign the form to certify under penalties of perjury all
items listed in box 5. Return the form to the address below.
Failure to Furnish TIN - If you fail to furnish your correct TIN to a requestor, you are subject to a penalty of $50 for each such failure unless your
failure is due to reasonable cause and not willful neglect.
Civil Penalty for False Information With Respect to Withholding – If you make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.
Criminal Penalty for Falsifying Information – Willfully falsifying certifications or affirmations may subject you to criminal penalties including
fines and/or imprisonment.
Misuse of TINs – If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.
SIGNATURE: Sign the form to certify that the information on the form is valid. Print or type your name below the signature.
Return this form by mail to: Oregon Department of Administrative Services
State Controller’s Division
Statewide Financial Management System
155 Cottage St. NE U60
Salem, OR 97301-3970 This form may be faxed to: (503) 378-8940
AFTER READING THE INSTRUCTIONS you may contact SFMS at (503) 373-1044 ext. 240 for additional information. Thank you for your
To sign up for direct deposit payment service and receive convenient, electronic payments, log-in to
http://egov.oregon.gov/DAS/SCD/SFMS/ach.shtml on the Interrnet and click on Forms and Brochures.