ࡱ> VXU'` bjbj$$ 8HFFnnnJJJJ$n4).DDD ((((((($)hR,(n e^ (D(""" 8Dn(" (""$Vn$DD" N`J !$%,)04)$, -%! -$ -n$0 ""= Y (("4) ff REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION Substitute Form W-9 Each person/organization doing business with the Commonwealth must provide the following information or be subject to backup withholding. Top of Form 1AND/ORSocial Security NumberFederal Identification Number2 Dun & Bradstreet Number3Is this form being completed for disbursement of grant funds? Y __ N __ If yes, skip item 44Provide a general description of goods/services to be sold to the Commonwealth: 0*__ Other6__ CorporationA*__ Partnership2__ Federal Agency7*__ Sole Proprietor/Reportable IndividualB*__ Estate3__ State Agency8*__ Medical CorporationC*__ Trust4__ Local Government9__ Non-Reportable IndividualD*__ Limited Liability Company5__ Political Subdivision*Indicates vendor may be eligible to receive a form 1099 LEGAL NAME:TRADE NAME:Order Address : Contact Person:Telephone No.:E-mail Address: FAX No:   Remittance Address:Contact Person: Telephone No.:  THIS BUSINESS IS CERTIFIED BY THE VIRGINIA DEPARTMENT OF MINORITY BUSINESS ENTERPRISE AS: __ Small __ Woman-Owned __ Minority-Owned For information on VDMBE certification, visit their website at  HYPERLINK "www.dmbe.virginia.gov" www.dmbe.virginia.gov or call them at 804-786-6585  CERTIFICATION Under penalties of perjury, I certify that: The number(s) shown on this form is/are my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 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 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. 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 under reporting interest or dividends on your tax return. 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