Supplier Information Form and W-9 - CyberGrants



American Honda

Supplier Information Form and W-9

|Key Contact Name: |- |Contact Phone No.: |      |

|E-mail Address: |      |

|Remit-To Address : |      |

|E-mail Address (where Purchase Orders should be sent): |      |

|Fax No (where Purchase Orders should be faxed to): |      |

|Per SBA Classifications, which is your Company? |

|Choose One (Attach copy of Certificate from SBA): | |If Ethnic Minority Owned – Choose One |

| | |(Attach copy of Certificate form NMSDC) |

| Small Disadvantaged Business | HUBZone Small Business | | American-Indian | Asian-Indian |

| Veteran-Owned | Service Disabled Veteran-Owned | | Asian-Pacific | African-American |

| Small-Business | | Hispanic | |

| |

|Woman Owned (Attach copy of Certificate from WBENC): |

| Women-Owned | |

|Does your company accept VISA? | Yes | No |

|Form |Request for Taxpayer Identification Number and Certification | | | |Give form to the requestor. |

|W-9 | | | | |Do NOT send to the IRS |

|Please complete the following information. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide |

|us with the information, your payments may be subject to 28% federal income tax backup withholding. Also, if you do not provide us with this information, you may be |

|subject to a $50 penalty imposed by the Internal Revenue’s Section 6723. |

| |

|Please |Name as registered with the IRS | |

|Print | |      |

| |

| |Business Name, if different from above | |

| | |      |

|Check | |

|Appropriate Box | |Sole Proprietor | |Corpor|

| | | | |ation |

| |

| |Address (number, street, and apt or suite no.), City, State, Zip code | |

| | |      |

| |

|Taxpayer | |For individuals or sole proprietors, this is your social security number (SSN). | | |

|Identification |For other entities, it is your employer identification number (EIN). | | | | |

|Number |Social Security Number |or |Employer Identification Number |

| | |  | |

| |

|Part III: Certification |

|You must cross out item 2 below if you have been notified by the IRS that you are currently subject to backup withholding. |

|The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. |

| |

|Under penalties of perjury, I certify that: | |

|1. The number shown on this form is my correct taxpayer identification number (TIN), (or the TIN of my corporation/ partnership), 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 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 U.S. resident alien). |

| |

|Sign | |

|Here | |Signature> |Date> | |

| | |Title | | |

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