State of Wisconsin Administrative Services Division Department of Workforce Development Bureau of Finance 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.
Entity Designation (check only one) Required Legal Name (as entered with IRS) If Sole Proprietorship or LLC Single Owner, enter your Last, First, MI. Individual/Sole Proprietor
Corporation (includes service corporations) Limited Liability Company – Partnership Trade Name Limited Liability Company – Sole Proprietor Enter Business Name (if different from above) Limited Liability Company - Corporation
Hospital Exempt from Tax or Government Remit Address (where check should be mailed) Owned PO Box or Number and Street, City, State, ZIP + 4 Long Term Care Facility Exempt from Tax or Government Owned
All Other Entities
Taxpayer Identification Number (TIN)
Required Order Address (where order should be mailed; only if different from remit)
PO Box or number and street, City, State, ZIP + 4 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.
1099 Address (for return of 1099 form; 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 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.
3. I am a U.S. person (including a US resident alien).
Printed Name Printed Title Telephone Number
( ) Fold Fold Signature Date (mm/dd/yyyy)
For Agency Use Only
Agency Number Phone Number Contact
445 W-9 Jan Dahmen (608) 261-9465
1099 Jody Keller (608) 267-3400
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: DEPARTMENT OF WORKFORCE DEVELOPMENT Fax Number: (608) 266-0909 ATTN: 1099 AUDITOR
PO BOX 7946 Attn: 1099 Auditor
MADISON WI 53707 FIS-10098 DOA-6448 (R. 3/2010)
Instructions for Completing Taxpayer Identification Number Verification
Legal Name As entered with IRS acquisition or abandonment of secured property, or contributions you made to an IRA. The IRS uses the Individuals: Enter Last Name, First Name, MI numbers for identification purposes and to help verify Sole Proprietorships: Enter Last Name, First Name, the accuracy of your tax return. You must MI provide your TIN whether or not you are required to LLC Single Owner: Enter owner's Last Name, First file a tax return. Payers must generally withhold a Name, MI percentage of taxable interest, dividend, and certain All Others: Enter Legal Name of Business other payments to a payee who does not furnish a TIN to a payer. Certain penalties may also apply. Trade Name Individuals: Leave Blank What Name and Number to Give the Requester Sole Proprietorships: Enter Business Name For this type of account: Give name and SSN of: LLC Single Owner: Enter LLC Business Name 1. Individual The individual All Others: Complete only if doing business as a D/B/A 2. Two or more individuals (joint The actual owner of the account account) or, if combined funds, the first Remit Address 1 individual no the account Address where payment should be mailed. 3. Custodian account of a minor 2The minor (Uniform Gift to Minors Act) Order Address 14. a. The usual revocable savings The grantor-trustee Address where order should be mailed. Complete trust (grantor is also trustee) only if different from remit address. 1b. So-called trust account that The actual owner 1099 Address is not a legal or valid trust under state law Address where 1099 should be mailed. Complete only if different from remit address. 35. Sole proprietorship or Single-The owner Owner LLC Entity Designation For this type of account: Give name and EIN of: 36. Sole Proprietorship or Single- The owner Check ONE box which describes the type of Owner LLC business entity. 47. A valid trust, estate, or pension Legal entity Taxpayer Identification Number trust LIST ONLY ONE: Social Security Number OR 8. Corporate or LLC electing The corporation Employer Identification Number OR Individual corporate status on Form 8832 Taxpayer Identification Number. See “What Name and Number to Give the Requester” at right. 9. Association, club, religious, The organization charitable, educational, or If you do not have a TIN, apply for one immediately. other tax-exempt organization Individuals use federal form SS-05 which can be obtained from the Social Security Administration. 10. Partnership or multi-member The partnership Businesses and all other entities use federal form LLC SS-04 which can be obtained from the Internal Revenue Service. 11. A broker or registered The broker or nominee nominee Certification 12. Account with the Department The public entity of Agriculture in the name of a You must cross out item 2 under Certification if you public entity (such as a state have been notified by the IRS that you are currently or local government, school subject to backup withholding because you have district or prison) that receives failed to report all interest and dividends on your tax agricultural program payments return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or 1 List first and circle the name of the person whose number you abandonment of secured property, cancellation of furnish. If only one person on a joint account has an SSN, that debt, contributions to an individual retirement person’s number must be furnished. arrangement (IRA), and generally, payments other 2 Circle the minor’s name and furnish the minor’s SSN. 3than interest and dividends, you are not required to You must show your individual name, but you may also enter your business or “DBA” name. You may use either your SSN or sign the Certification, but you must provide your EIN (if you have one). correct TIN. 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 Privacy Act Notice trustee unless the legal entity itself is not designated in the account title.) Section 6109 requires you to furnish your correct TIN
to persons who must file information returns with the NOTE: If no name is circled when more than one name is IRS to report interest, dividends, and certain other listed, the number will be considered to be that of the first income paid to you, mortgage interest you paid, the name listed