ࡱ> UZTa &bjbj[[ ;D9bE\9bE\0 84FD+|+~+~+~+~+~+~+$-E0+#N##++%%%#<|+%#|+%%:),J|*@R$(* h++0+2*R0%"0*0*% ]!=++2%v+####0> :   INSTRUCTIONS 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. 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 ORGANIZATION TYPE and NAME must be for the same entity. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): Verify that the FEIN is correct for the entity named on the form. If the FEIN 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: Sole Proprietor - Any business or venture owned by a single person. Give name of the owner. Partnership, LLC, LLP, TRUST - Any business or venture owned by two or more partners. Corporation, Not Medical or Attorney -Any corporation formed under the laws of any U.S. state or territory except for not for profit, governmental, medical/health care or attorneys. Medical/Health Care - Any business or venture that provides medical or health care services, either incorporated or not incorporated. Attorney-At-Law - Attorney-at-Law, either incorporated or non-incorporated. Not for Profit - Any non-profit organization formed under the laws of any U.S. state or territory. A copy of your EXEMPTION LETTER from the IRS is required. Government Agency - Any part of the government of the United States or of any state. Local Government - Any local government agency or political subdivision of the State of Oregon. 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. PENALTIES- Failure to Furnish TIN - If you fail to furnish your correct TIN to a requestor, you are subject to a penalty of $100 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 Enterprise Goods & Svcs/Financial Business Svcs Statewide Financial Management Services 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) 373-0256 for additional information. Thank you for your cooperation. ----------------------------------------------------------------------------------------------------------------------------------- To sign up for direct deposit payment service and receive convenient, electronic payments, log-in to HYPERLINK "http://www.oregon.gov/DAS/Financial/AcctgSys/pages/ach.aspx"http://www.oregon.gov/DAS/Financial/AcctgSys/pages/ach.aspx on the Interrnet and click on Forms and Brochures.     REVISED  DATE \l 3/21/2016 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 (Substitute) 3. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) You must provide your FEIN whether or not you are required to file a tax return. Payers must generally withhold at the current IRS backup withholding rate for taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. See back of form for applicable penalties and instructions. NAME & ADDRESS Telephone: Fax: 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. 2. BUSINESS NAME You may enter your business, trade, or doing business as (DBA) name on the Business Name line. State Use Only V I O 5 Y T 5 N O 5 Y N 5 Y P 5 N G 3 N G 4 N G 4. ORGANIZATION TYPE You Must Check One Only. Make sure that the organization type corresponds to the tax identification number in box 3. ____ Sole Proprietor, Partnership, LLC, LLP, Trust ____ Corporation, not Medical or Attorney ____ Medical Health Care, Incorporated or not Incorporated ____ Attorney-At-Law ____ Not for Profit (copy of Exemption Letter from the IRS is required) ____ State/Federal Government Agency ____ Local Government/Political Subdivision The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. AUTHORIZED SIGNATURE ________________________________________________________________________________ NAME (print or type) _______________________________________________________________________________________ TITLE _______________________________________ DATE _____________________________________________ (If representing a business/organization) To sign up for direct deposit payment service and receive convenient, electronic payments, log-on to: HYPERLINK "http://www.oregon.gov/DAS/Financial/AcctgSys/pages/ach.aspx"http://www.oregon.gov/DAS/Financial/AcctgSys/pages/ach.aspx on the internet. Select a vendor form in .pdf or .docx format. 5. The number shown on this form is my correct taxpayer identification number, and I am a U.S. person (including a U.S. resident alien), and READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE RESPONDING TO THE NEXT ITEM Under penalties of perjury, I certify that 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 the IRS has notified me that I am no longer subject to backup withholding. 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