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Corporate Payables
(Phone) 855-267-7729
Corporatepayablesnewvendorgroup@usbank.com
Effective 04/2021
Return completed form to U.S. Bank New Vendor
Set-up via e-mail or US Postal Mail as indicated on
the instruction page.
Vendor Number:
Section I: W-9
Must be completed and returned for payments to be processed.
1 Name (as shown on your income tax return)
2 Business name/disregarded entity, if different from above
3 Address
City
State
ZIP
4 Payment Remittance Address
City
State
ZIP
5 Phone
6 Email
7 Federal Taxpayer Identification Number (TIN)*
TIN Type (Check one)
Social Security Number
Employer Identification Number
*MUST match the name given on line 1 to avoid backup withholding
8 Federal Tax Classification
Individual/Sole Proprietorship or single-
member LLC
C Corporation
S Corporation
Partnership
Trust/Estate
Other, please specify
10 Exemptions
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
(Applies to accounts maintained outside the U.S.)
9 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P= Partnership)
Reference Section 1: W-9 Information for details regarding LLC and classification.
Section 2: Payment Options
Authorization Agreement for Automatic Deposits (ACH Credits)
I (We) hereby authorize U.S. Bank, on behalf of any affiliate for which it processes payments, hereinafter called COMPANY, to initiate credit
entries to my (our) account indicated below and the depository/financial institution named below, hereinafter called BANK, to credit the same
to such account.
E-mail address1 (to receive electronic remittance advices)
E-mail address2
Checking Account Information (Please attach a voided check or copy of a check with MICR coding)
Routing/ABA Number
Account Number
Bank Name
Branch
City
State
ZIP
Phone
Check this box if you are interested in the virtual credit card option.
This authority is to remain in full force and effect until COMPANY has received written notification from me (us) of its termination in such time
and in such manner as to afford COMPANY and DEPOSITORY a reasonably opportunity to act on it.
Section 3: Certification
Under penalties of perjury, I certify that:
1.
The number show 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 back up 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; and
4.
The FACTA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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 you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding. An ink signature is required for this form to be processed. U.S. Bank’s policy does not accept W-9 forms with electronic signatures,
unless the electronic system is implemented and controlled by U.S. Bank. Please sign with an ink signature below.
Name (Print):
Title:
Signature of a U.S. person
Date
Instructions
Sections 1, 2, 3 (Name (Print) and Title) and 4 must be filled out
electronically. Fill out by clicking on the fill in the blanks and type in the
information. Section 3: Signature of a U.S. Person and Date must be
hand-written. The form will be rejected if not filled out correctly.
Rev1.7
CITY OF EL MIRAGE
10000 N EL MIRAGE RD
EL MIRAGE
AZ
85335
10000 N EL MIRAGE RD
EL MIRAGE
AZ
85335
623-972-8116
VOJEDA@ELLMIRAGEAZ.GOV 86-6000767
GOVERNMENT
3
C
VOJEDA@ELMIRAGEAZ.GOV
KJONES@ELMIRAGEAZ.GOV
122100024
634956635
CHASE
373
SURPRISE
ARIZONA
85379
1-623-975-3932
JENNIFER CRYSTAL DYCHES
CITY MANAGER
09/03/2025
Reset
Print
U.S. Bank W-9 & Related Information
Page 2
Corporate Payables
(Phone) 855-267-7729
Corporatepayablesnewvendorgroup@usbank.com
Effective 04/2021
Section 4: MWBEs, DVBEs & DOBEs
Minority and Women Owned Business Enterprises (MWBE) - U. S. Bank is committed to building relationships with certified MWBEs, defined
as companies that are at least 51 percent owned, controlled and managed by one or more of the following categories - African American,
Hispanic American, Asian Pacific American, Asian Indian American, Native American, Woman. Please include a copy of certification.
Disabled Veteran Business Enterprise (DVBE) - The law defines a disabled veteran as a United States military, naval or air service veteran
with a service related disability of at least 10 percent. Please include a copy of certification.
Disabled Owned Business Enterprise (DOBE) - A disabled-owned business is a business that is at least 51 percent owned, controlled and
operated by an individual or individuals who are disabled. Please include a copy of certification.
Section 4: MWBE, DVBE & DOBE
Is your company certified as a minority/ woman owned business?
No
Yes (if yes, a copy of your minority/woman owned certification MUST BE INCLUDED)
MWBE Business Status (check all that apply):
African American
Hispanic American
Asian Pacific American
Asian Indian American
Native American
Woman
Is your company certified as a Disabled Veteran Business Enterprise?
No
Yes (if yes, a copy of your DVBE certification MUST BE INCLUDED)
This will certify to U.S. Bank that I have read the requirements cited on this form, and the company classification(s) I have selected above are
true and correct. I will advise U.S. Bank if our classification should change.
Is your company certified as a Disabled Owned Business Enterprise?
No
Yes (if yes, a copy of your DOBE certification MUST BE INCLUDED)
Rev1.7
U.S. Bank W-9 & Related Information
Form instructions
Corporate Payables
(Phone) 855-267-7729
Corporatepayablesnewvendorgroup@usbank.com
Effective 04/2021
Vendor Number: To be completed by U.S. Bank’s Corporate Payables department.
Section 1: W-9 information
U.S. Bank requires your taxpayer identification number (TIN) to report on an information return the amount paid to you, or other income
reportable on an information return. Please complete Section 1 in its entirety. A federal tax classification must be selected. If exemptions
from backup withholding (exempt payee codes) or Foreign Account Tax Compliance Act (FATCA) reporting (FATCA reporting codes) apply to
you, please ensure that the exemption code is entered. The FATCA reporting code is only for vendor invoices originated outside the U.S.
Exempt payee codes:
1 – An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2)
2 – The United States or any of its agencies or instrumentalities
3 – A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities
4 – A foreign government or any of its political subdivisions,
agencies or instrumentalities
5 – A corporation
6 – A dealer in securities or commodities required to register in
the United States, District of Columbia, or a possession of the
United States
7 – A futures in securities or commodities required to register in
the United States, the District of Columbia, or a U.S.
commonwealth or possession
8 – A real estate investment trust
9 – An entity registered at all times during the tax year under the
investment Company Act of 1940
10 – A common trust operated by a bank under section 584(a)
11 – A financial institution
12 – A middleman known in the investment community as a
nominee or custodian
13 – A trust exempt from tax under section 664 or described in
section 4947
Exemption from FATCA reporting code:
A – An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37)
B – The United States or any of its agencies or instrumentalities
C – A state, the District of Columbia, a U.S. commonwealth or possession,
or any of their political subdivisions or instrumentalities
D – A corporation the stock of which is regularly traded on one or more
established securities markets, as described in Regulations section
1.1472-1(c)(1)(i)
E – A corporation that is a member of the same expanded affiliated group
as a corporation described in Regulations section 1.1472-1(c)(1)(i)
F – A dealer in securities, commodities, or derivative financial instruments
(including notional principal contracts, futures, forwards, and options) that
is registered as such under the laws of the United States or any state
G – A real estate investment trust
H – A regulated investment company as defined in section 851 or an entity
registered at all times during the ta year under the Investment Company
Act of 1940
I – A common trust fund as defined in section 584(a)
J – A bank as defined in section 581
K – A broker
L – A trust exempt from tax under section 664 or described in section
4947(a)(1)
M – A tax exempt trust under a section 403(b) plan or section 457(g) plan
For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See
Regulations section 301.7701-2(c)(2)(iii). Enter the owner’s name on line 1. The name of the entity entered on line 1 should never be a
disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported.
Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box
on line 3. For a single-member owner, check the appropriate box for the tax classification of the single-member owner. Do not check LLC if the
LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not
disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check
the appropriate box or the tax classification of its owner.
If the entity/person on line 1 is a(n)….
THEN check the box for…
• Corporation
Corporation
• Individual
• Sole proprietorship, or
• Single-member limited liability company (LLC) owned by an individual and
disregarded for U.S. federal tax purposes.
Individual/sole proprietor or single-member LLC
• LLC treated as a partnership for U.S. federal tax purposes,
LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or
• LLC that is disregarded as an entity separate from its owner but the owner is
another LLC that is not disregarded for U.S. federal tax purposes.
Limited liability company and enter the appropriate tax
classification (P=Partnership; C= C corporation; or S= S
corporation)
• Partnership
Partnership
• Trust/estate
Trust/estate
Section 2: Payment Options
ACH, will allow U.S. Bank to pay you (vendor) through an automated electronic deposit into your preferred checking/savings account. Please
acquire your routing number and account number from a check (not from a deposit slip). A virtual credit card options is also available should
you already be a Visa accepter. A remittance advice detailing the invoice number(s), date and dollar amount will be sent to you via e-mail (if
provided) or by mail when the electronic payment has been sent to your account. If you are interested in the virtual credit card, contact us for
more information at corporatepayablesnewvendorgroup@usbank.com .
Submission
Please submit the completed form to Corporate Payables New Vendor Group. U.S. Bank will not process pending invoices or Expense Check
Requisitions without a properly completed W-9 form on file.
E-mail
CorporatePayablesNewVendorGroup@usbank.com