State of Wisconsin Division of Executive Budget and Finance Department of Administration State Controller’s Office DOA-6448 (R09/2004)
Substitute W-9 DO NOT send to IRS
Taxpayer Identification Number (TIN) Verification
Print or Type Please see attachment or reverse for complete instructions. This form can be made available in alternative formats to qualified individuals upon request.
Legal Name (as entered with IRS) Entity Designation (check only one) Required If Sole Proprietorship or LLC Single Owner, enter your Last, First, MI Individual/Sole Proprietor/LLC Single Owner
Corporation (includes service corporations) Limited Liability Company - Partnership Trade Name Limited Liability Company - Corporation Enter Business Name if different from above. Government Entity Hospital Exempt from Tax or Government Owned Remit Address (where check should be mailed) Long Term Care Facility Exempt from Tax or PO Box or Number and Street, City, State, ZIP + 4 Government Owned
All Other Entities
Taxpayer Identification Number (TIN)
If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you show the SSN. Order Address (where order should be mailed; complete only if different from remit)
PO Box or number and street, City, State, ZIP + 4
___ ___ ___ ___ ___ ___ ___ ___ ___
1099 Address (for return of 1099 form; complete only if different from remit) Check Only One Required (see “Instructions”) PO Box or number and street, City, State, ZIP + 4 Social Security Number (SSN)
Employer Identification Number (EIN) Individual Taxpayer Identification Number for U.S. Resident Aliens (ITIN)
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 back up 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 back up 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.
3. I am a U.S. person (including a US resident alien).
Printed Name Printed Title Telephone Number
( ) Signature Date (mm/dd/ccyy)
For Agency Use Only
Agency Number Contact Phone Number
Name Address Other (explain)
Return completed form via facsimile machine or to the address listed below.
For your convenience this form has been designed for return in a standard Window envelope.
Forms may be returned to:
Fax Number: ( )
Instructions for Completing Taxpayer Identification Number Verification
Legal Name As entered with IRS identification purposes and to help verify the accuracy of your tax return. You must provide your TIN whether or Individuals: Enter Last Name, First Name, MI not you are required to file a tax return. Payers must Sole Proprietorships: Enter Last Name, First Name, MI generally withhold 29% of taxable interest, dividend, and LLC Single Owner: Enter owner's Last Name, First Name, certain other payments to a payee who does not furnish a MI TIN to a payer. Certain penalties may also apply. All Others: Enter Legal Name of Business Trade Name What Name and Number to Give the Requester Individuals: Leave Blank For this type of account: Give name and SSN of: 1. Individual The individual Sole Proprietorships: Enter Business Name LLC Single Owner: Enter LLC Business Name 2. Two or more individuals (joint The actual owner of the account All Others: Complete only if doing business as a D/B/A account) or, if combined funds, the first individual no the account 1 Remit Address 3. Custodian account of a minor (Uniform Gift to Minors Act) The minor 2 Address where payment should be mailed. 4. a. The usual revocable savings Order Address The grantor-trustee trust (grantor is also trustee) 1 Address where order should be mailed. Complete only if b. So-called trust account that is not a legal or valid trust different from remit address. The actual owner 1 under state law 1099 Address 5. Sole proprietorship or Single- Owner LLC Address where 1099 should be mailed. Complete only if The owner 3 different from remit address. For this type of account: Give name and EIN of: Entity Designation 6. Sole Proprietorship or Single- The owner 3 Owner LLC Check ONE box which describes the type of business 7. A valid trust, estate, or pension entity. Legal entity 4 trust Taxpayer Identification Number 8. Corporate or LLC electing The corporation corporate status on Form LIST ONLY ONE: Social Security Number OR Employer 8832 Identification Number OR Individual Taxpayer 9. Association, club, religious, Identification Number. See “What Name and Number The organization charitable, educational, or to Give the Requester” at right. other tax-exempt organization If you do not have a TIN, apply for one immediately. 10. Partnership or multi-member The partnership LLC Individuals use federal form SS-05 which can be obtained from the Social Security Administration. Businesses and 11. A broker or registered all other entities use federal form SS-04 which can be The broker or nominee nominee obtained from the Internal Revenue Service. 12. Account with the Department The public entity of Agriculture in the name of a Certification public entity (such as a state or local government, school You must cross out item 2 above if you have been district or prison) that receives notified by the IRS that you are currently subject to agricultural program payments 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 1 List first and circle the name of the person whose number you furnish. individual retirement arrangement (IRA), and generally, If only one person on a joint account has an SSN, that person’s number must be furnished. payments other than interest and dividends, you are not 2 Circle the minor’s name and furnish the minor’s SSN. required to sign the Certification, but you must provide 3 You must show your individual name, but you may also enter your your correct TIN. business or “DBA” name. You may use either your SSN or EIN (if you have one). Privacy Act Notice 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 Section 6109 requires you to furnish your correct TIN to the legal entity itself is not designated in the account title.) persons who must file information returns with the IRS to report interest, dividends, and certain other income paid 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. 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
Taxpayer Identification Request
In order for the State of Wisconsin to comply with the Internal Revenue Service regulations, this letter is to request that you complete the enclosed Substitute Form W-9. Failure to provide this information may result in delayed payments or backup withholding. This request is being made at the direction of the Wisconsin State Controller in order that the State may update its vendor file with the most current information.
Please return or FAX the Substitute Form W-9 even if you are exempt from backup withholding within (10) days of receipt. Please make sure that the form is complete and correct. Failure to respond in a timely
manner may subject you to a 29% withholding on each payment or require the State to withhold payment of outstanding invoices until this information is received.
We are required to inform you that failure to provide the correct Taxpayer Identification Number (TIN) / Name combination may subject you to a $50 penalty assessed by the Internal Revenue Service under section 6723 of the Internal Revenue Code.
Only the individual’s name to which the Social Security Number was assigned should be entered on the
The name of a partnership, corporation, club, or other entity, must be entered on the first line exactly as it was registered with the IRS when the Employer Identification Number was assigned.
DO NOT submit your name with a Tax Identification Number that was not assigned to your name. For example, a doctor MUST NOT submit his or her name with the Tax Identification Number of a clinic he or she is associated with.
Thank you for your cooperation in providing us with this information. Please return the completed form to: