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*Taxpayer ID:
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If a Foreign company, use IRS Form W-8 available at IRS.gov
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*Payment Method:
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Please make any notes regarding payments in box below.
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Applicant Information:
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* Applicant Name
(individual or entity)
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Name on IRS record (if different from above):
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Applicant Remittance Address:
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* Address Line 1:
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Address Line 2:
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* City:
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* State:
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* Zip:
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* Contact Name:
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* Phone #:
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( ) - Extension:
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Fax #:
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( ) -
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Contact E-mail address:
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Applicant Ordering Address:
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* Address Line 1:
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Address Line 2:
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* City:
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* State:
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* Zip:
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-
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* Contact Name:
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* Phone #:
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( ) - Extension:
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Fax #:
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( ) -
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Contact E-mail address:
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Additional Reporting Elements:
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Please check all that apply:
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Veteran-Owned Small Business
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* 1099 Withholding Type and Class:
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(Default reportable status is Non-Employee Compensation)
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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).
Definition of a U.S. Person. For federal tax purposes, you are considered a U.S. person if you are:
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An individual who is a U.S. citizen or U.S. resident alien,
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A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,
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An estate (other than a foreign estate), or
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A domestic trust (as defined in regulations section 301.7701-7)
Electronic System Submission:
Under penalties of perjury I certify that:
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
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