W-9 Form


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Request for Taxpayer Identification Number and Certification
(City of Roanoke Substitute W-9 Form)
What is this?

City Vendor Number if previously assigned:

* Name (List legal name, if joint names, list first the name of the peson whose TIN you enter in Part I - See Specific Instructions on page 2.)

Business Name, if different from above. (See Specific Instructions on page 2.)

Check appropriate box: Individual Sole Proprietor Corporation Partnership Other

Legal Address: number, street, and apt. or suite no.

City, state and ZIP code
,

Phone #
( )

Fax #
( )

Email Address

City Procurement Officer (Indicate if none.)

Remittance Address: if different from legal address.

Remittance City, state and ZIP code
,

Remittance Phone #
( )

Remittance Fax #
( )

Remittance Email Address

Remittance Contact Person

Part I
Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. 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 3 for guidelines on whose number to enter.

Social Security Number

- -

OR
Employee Identification Number

-

Part II
Certification

Under pentalities of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number, and

2. I am not subject to backup withholding because (a) I am exempt from backup withholding, (b) I have not been notified by the 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. person (including a U.S. resident alien).

Certification instructions. Please check this box 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, this does not apply.

Sign Here

What is this?
Authorized Signature ►

Date ► 11/21/2009

Supplemental Vendor Information(Check ALL that apply): City of Roanoke Employee Roanoke City Public Schools employee

Rent
Small Business Minority Owned Business Women Owned Business

Social Services Vendors only Day Care Provider Foster Care / Adoptive Parent Other Social Services Provider

November 21, 2009