GAO-W-9 STATE OF ARIZONA SUBSTITUTE W-9.PDF
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State of Arizona Substitute W-9: Request for Taxpayer Identification Number and Certification Submit completed form to the State of Arizona Agency with whom you are doing business with for review and authorization. 1 Type of Request (Must select at least ONE) Change - Select the type(s) of change from the following: New Location (Additional Address ID) New Request Tax ID Legal Name Entity Type Minority Business Indicator Main Address Remittance Address Contact Information 2 Taxpayer Identification Number (TIN) (Provide ONE Only) TIN - OR SSN - - 3 Entity Name (As it appears on IRS EIN records, IRS Letter CP575, IRS Letter 147C or Social Security Administration Records, Social Security Card. If Individual, Sole Proprietor, Single Member LLC, enter First, Middle, Last Name.) Legal Name DBA Name 4 Entity Type (Must select ONE of the following) Individual/Sole Proprietor or Single-Member LLC Corporation Partnership Limited Liability Company (LLC) including Corporations & Partnerships The US or any of its political subdivisions or instrumentalities A state, a possession of the US, or any of their political subdivisions or instrumentalities Other: Tax Reportable Entity Other: Tax Exempt Entity Description 5 Minority Business Indicator (Must select ONE of the following) Small Business Small Business- African American Small Business- Asian Small Business - Hispanic Small Business- Native American Small Business- Other Minority Small, Woman Owned Business Small, Woman Owned Business- African American Small, Woman Owned Business- Asian Small, Woman Owned Business- Hispanic Small, Woman Owned Business- Native American Small, Woman Owned Business- Other Minority Woman Owned Business Woman Owned Business- African American Woman Owned Business- Asian Woman Owned Business- Hispanic Woman Owned Business- Native American Woman Owned Business- Other Minority Minority Owned Business- African American Minority Owned Business- Asian Minority Owned Business- Hispanic Minority Owned Business- Native American Minority Owned Business- Other Minority Non-Profit, IRC §501(c) Non-Small, Non-Minority or Non-Woman Owned Business Individual, Non-Business 6 Veteran Owned Business NO YES 7 Entity Address Main Address (Where tax information and general correspondence is to be mailed) Address Line 1 Address Line 2 City State Zip code Remittance Address (Where payment is to be mailed) Same as Main Address Line 1 Address Line 2 City State Zip code 8 Vendor Contact Information Name Title Phone Ext. Fax Email 9 Exemption from Backup Withholding and FATCA Reporting: Complete this section if it is applicable to you. See instructions for more details Exemption Code for Backup Withholding Exemption Code for FATCA Reporting 10 Certification Under penalties 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, or (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 US citizen or other US person, and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. 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. Signature Print Name Date GAO-W-9 (10/2019) The State of Arizona Substitute W-9 Form Instructions The State of Arizona (State), like all organizations that file an information return with the IRS, must obtain your correct Taxpayer Identification Number (TIN) to report income paid to you or your organization. The State uses the Substitute W-9 Form to obtain certification of your TIN in order to ensure accuracy of information contained in its payee/vendor system and to avoid Backup Withholding as mandated by the IRS. According to IRS regulations, the State must withhold 28% of all payments if a vendor/payee fails to provide the State its certified TIN. The Substitute Form W-9 certifies a vendor/payee's TIN. Any vendor/payee who wishes to do business with the State must complete the Substitute W-9 Form. Part 1 - Type of Request: Select only one. Part 2 - Taxpayer Identification Number (TIN): Enter your nine-digit TIN. The TIN is either your nine-digit Social Security Number (SSN) assigned by the Social Security Administration (SSA) or Employer Identification Number (EIN) assigned by the Internal Revenue Service (IRS). Part 3 - Entity Name: Enter the legal name as it appears on IRS EIN records, IRS Letter CP575, IRS Letter 147C or Social Security Administration Records, Social Security Card. If Individual, Sole Proprietor, Single Member LLC, enter First, Middle, Last Name. Enter your DBA in the designated line if applicable. Part 4 - Entity Type: Select only one for TIN given. Part 5 - Minority Business Indicator: Select only one for TIN given. Part 6 - Veteran Owned Business: Select only one for TIN given. Part 7 - Entity Address: List the locations for tax reporting purposes and where payments should be mailed. Part 8 - Entity Contact Information: List the contact information. Part 9 - Backup Withholding and FATCA Exemptions: If you are exempt from Backup Withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. Backup Withholding Exemption Codes: Generally, Individuals (including Sole Proprietors) are not exempt from Backup Withholding. Additionally, Corporations are not exempt from Backup Withholding when supplying legal or medical services. If you do not fall under the categories below, leave this field blank. The following codes identify payees that are exempt from Backup Withholding: Code 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) Code 2: The United States or any of its agencies or instrumentalities Code 3: A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or Instrumentalities Code 4: A foreign government or any of its political subdivisions, agencies, or instrumentalities Code 5: A corporation Code 6: A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States Code 7: A futures commission merchant registered with the Commodity Futures Trading Commission Code 8: A real estate investment trust Code 9: An entity registered at all times during the tax year under the Investment Company Act of 1940 Code 10: A common trust fund operated by a bank under section 584(a) Code 11: A financial institution Code 12: A middleman known in the investment community as a nominee or custodian Code 13: A trust exempt from tax under section 664 or described in section 4947 FATCA Exemption Codes: The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. If you are only submitting this form for an account you hold in the United States, leave this field blank. The following codes identify payees that are exempt 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) Code B: The United States or any of its agencies or instrumentalities Code C: A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities Code D: A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472-1(c)(1)(i) Code E: A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c) (1) (i) Code 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 Code G: A real estate investment trust Code H: A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 Code I: A common trust fund as defined in section 584(a) Code J: A bank as defined in section 581 Code K: A broker Code L: A trust exempt from tax under section 664 or described in section 4947(a) (1) Code M: A tax-exempt trust under a section 403(b) plan or section 457(g) plan Part 10 - Certification: Please sign, date and provide preparer's name in appropriate space. GAO-W-9 (10/2019)