Substitute Form W-9
Request for Taxpayer
Identification Number and Certification
Name (as shown on your income tax return)
Print or Type
Business name, if different from above
□ Individual/Sole proprietor □ Corporation □ Partnership
□ Limited Liability company. Enter tax classification (D=disregarded entity, C=corporation, P=partnership) ► -------- □ Exempt
Payee
□ Other (see instructions) ►
Check appropriate box:
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Social security number
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to
avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get
a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for
guidelines on whose number to enter. (Instructions referred to above can be found at the IRS W9
website provided below.)
Part II
or
Employer identification number
Certification
Under penalties of perjury, I certify that:
1. The number shown 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 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 (defined below).
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 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. See the instructions on
page 4.
Sign
Here
Signature of
U.S. person ►
Date ►
General Instructions, and a fill-in W9 form, can be found at the following government website: http://www.irs.gov/pub/irspdf/fw9.pdf Section references are to the Internal Revenue Code unless otherwise noted.
Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar
to the Form W-9.
Please complete this Form W-9 and the Vendor Survey on the other side
within 10 days of receipt to avoid delays in the purchasing and/or payment
process.
Return to the following address:
University of Wisconsin-Platteville
Pioneer Academic Center for Community Engagement (PACCE)
1 University Plaza
Platteville, WI 53818-3099
UW-PLATTEVILLE Vendor Classification Survey
Business Name____________________________________________________________
Address__________________________________________________________________
Address__________________________________________________________________
City_________________________________ St_______________ Zip Code__________
Vendor Classification: Please Check Appropriate Box
Attorney
Attorney or Corporation of Attorneys
Corporation
Corporation Or LLCs designated as a corporation United States Corporations only
Employee
Current active Employee of UW Institution
Individual/Sole Proprietor
Individual or Individual doing business by another name.
Nonprofit
An entity designated by the IRS as a non-profit entity
Other
Other is indicated to self-identify a vendor that does not fall into any other category.
Partnership/LLC
Only a United States registered LLC. LLC = Limited Liability Company
Student
A current enrolled student in a UW-Institution.
Vendor Type: Please Check All That Apply
Educational Institution
All educational institutions.
Foreign Vendor
Business Entity with headquarters outside the United States
Intergovernmental
A local agency, board, commission, committee, council, department, or
public body created by constitution, statute, ordinance, rule, or order.
Wisconsin Certified Minority Vendor
A Wisconsin Certified Minority Vendor
Wisconsin Certified Woman Owned
Minority Vendor
Wisconsin Certified Woman Owned Minority
Wisconsin Certified Woman Owned Vendor
WI Certified Sheltered Workshop
A Wisconsin Certified Woman Owned Vendor as indicated on the vendor
survey or other documentation.
An occupation-oriented facility operated by a not-for-profit corporation,
which except for staff, employs only handicapped persons.
Woman Owned Business
A Woman Owned Business that is not WI Certified.
HUBZone (Historically Underutilized
Business Zone)
A designation from the Small Business Administration that identifies
disadvantaged geographical areas in which the federal government
encourages commerce.
Small Disadvantaged Business
A firm that has registered with the federal government as an SDB
Other Certified Minority Businesses
Self-Certified Minority Business
Other Veteran Owned Small Business
Service Disabled Veteran Owned Small
Business
Minority vendors certified by other entities, i.e. other states, counties, cities
or US federal government agency.
A self certified minority business is an entity that has not formally
registered for Small Disadvantaged Business as a Minority Business but
wishes to claim their minority status.
Veteran Owned Small Business. A designation from the Small Business
Administration that identifies businesses principally owned by veterans,
with whom the federal government encourages commerce.
A designation from the Small Business Administration that identifies
businesses principally owned by veterans disabled during their service,
with which the federal government encourages commerce.