IRS Form W-9

California Institute of Technology ♦ Supplier Management MC 103-6 ♦ Pasadena, CA 91125 Please complete and return the Internal Revenue Service (IRS) Form W-9 below and the supplemental payee information sheet on the back of this letter. According to federal regulations, a completed IRS Form W9 is required of all our payment recipients. The purpose of the IRS Form W-9 is to provide us with your correct taxpayer identification number (TIN). We realize you may not be subject to tax reporting due to your business status. However, in order to make this determination we must have an IRS Form W-9 on file. The supplemental payee information is needed to verify your most recent mailing address and other pertinent payment information. Small Business Utilization As a recipient of federal funds, we are required to assess the volume of business we transact with suppliers that are classified as Small Business, Historically Black Colleges/Universities, HUBZone Small Business, Small Disadvantaged Business, Women Owned Small Business, Service Disabled Veteran Owned and Veteran Owned Small Business enterprises. In order to provide that information, we are required to maintain a completed Supplier Profile form for each supplier/consultant that is categorized as one of the above. If you classify as a Small Business (less than 500 employees), please complete the Supplier Profile Form in addition to the IRS Form W-9. ∗∗∗∗∗∗∗∗∗∗ Due within 10 days of receipt ∗∗∗∗∗∗∗∗∗∗ Use the enclosed envelope to return your completed forms, or Fax to Supplier Management at (626)666-3928 (please fax both sides of this form) Primary contact, Rebekah Sims at (626)395-2674 or alternate contact, Hotline at (626)395-8900 Exemption: If exempt from reporting, check here AND circle your qualifying exemption reason below: 4. A state, the District of 5. A foreign government Columbia, a possession or any of its political of the United States, or any subdivisions. of their political subdivisions. 1. Corporation, 2. Tax Exempt 3. The United States or excludes medical, Charity under any of its agencies healthcare payments, or 501(a) (includes or instrumentalities. payments for legal services. 501(c) (3), or IRA. Part II Certification: I am a U.S. person (including a resident alien). Person completing this form: _________________________________________ Title: ____________________________ Signature: ________________________________________________________ Date: ____________________________ Tax correspondence address: __________________________________________________________________________ Phone: (________) ________________________________ W9 Form/September 2005 Supplier #: ________ California Institute of Technology ♦ Supplier Management MC 103-6 ♦ Pasadena, CA 91125 Payee Information: Payee Name: Is the above payee doing business under another name? If yes, please list business name: Customer #: (Please specify the customer number your business assigns Caltech) Yes No Caltech delivers Purchase Orders (PO) electronically to a fax or email address Please choose your preferred method of PO delivery: Address: Fax Email Phone: ( ) Fax: ( ) Email Address: Website: Make checks payable to: Remit Address: Is your company registered to do business within the State of California: Resale Permit Number: Primary NAICS Code (6-digits): Does your business accept MasterCard: Contact Name (first and last): Contact Phone: Yes No (For more information see http://www.census.gov/epcd/www/naics.html) Yes No Contact Email: Large Business Small Business (please complete Supplier Profile Form attached) ******** Due within 10 days of receipt ******** W9 Form/September 2005 California Institute of Technology ♦ Small Business Program ♦ MC 103-6 ♦ Pasadena, CA 91125 Supplier Profile Form The California Institute of Technology is continuing to build its Small Business Resource Directory consisting of small businesses, which it contacts through its outreach program. If you wish to have your business added to our database and listed in our online resource directory, please complete both sides of this form and return it to the address listed above or you may fax both sides of this form to (626)666-3928, Attn: Small Business Program. If you have any questions, please contact Genger Richmond at (626)395-2895 or Rebekah Sims at (626)395-2674. If you require assistance in determining the size and status of your organization or your primary North American Industry Classification System (NAICS) code, please contact the United States Small Business Administration (SBA) at 1-800-U-ASKSBA. Further information and definitions are also available on the SBA’s website: www.sba.gov. Name: Doing Business As (dba): Address: City: Phone: ( ) State: Fax: ( ) Zip: Website: Email: Business Classification Are you classified as a small business? Yes No Business Concern (check all that apply) Historically Black College/University or Minority Institution HUBZone Small Business (please attach copy of SBA certification) Number of Employees: Annual Sales: $ Primary NAICS Code: Minority Owned Business Small Disadvantaged Business (please attach copy of SBA certification) Service Disabled Veteran Owned Small Business Veteran Owned Small Business Woman Owned Business Penalties and Remedies for Misrepresentation of Business Status Under 15 U.S.C 645(d), CFR 121 any person who misrepresents a firm’s status as a small, small disadvantaged, women-owned, or HUBZone small business concern in order to obtain a contract to be awarded under preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal Law that specifically references section 8(d) for definition of program eligibility, shall (i) be punished by imposition of fine, imprisonment, or both; (ii) be subject to administrative remedies, including suspension and debarment; and (iii) be ineligible for participation in programs conducted under the authority of the Act. Supplier Profile Form/September 2005 Turn page over California Institute of Technology ♦ Small Business Program ♦ MC 103-6 ♦ Pasadena, CA 91125 Product/Services Category List: Our Small Business Resource Directory sorts listings using the categories listed below. Please check all that apply: Accommodations and Food Service/Supplies Animal Related Apparel Audio Visual Related Automotive Repair and/or Maintenance/Supplies Business Machines Computer Related Construction – Repair and/or Maintenance Consulting Electrical/Electronic/Mechanical Related Entertainment Related Gases Health Care Related Describe the products and/or services your company provides: Industrial Supplies Janitorial/Cleaning Related Laboratory Related Office Supplies Print/Copy Services and/or Supplies Professional Services Rentals Research Related Safety/Environmental Related Specialty Advertising/Gifts Telecommunication Travel Related List any higher education or research facility you have done business with: Certification: I CERTIFY THAT: 1) the business size, and/or 2) the characteristics of the firm’s ownership are accurately reflected as indicated above; 3) all information supplied herein (including all attachments) is correct; and 4) that neither the applicant nor any person or concern in any connection with the applicant as principal or officer, so far as known, is debarred or otherwise declared ineligible by any agency of the Federal and State Government from making offers for furnishing materials, supplies or services to the Government or any agency thereof. Signature (Company Official): Type or Print Name: If certifying as “Small”, is firm registered in CCR? Is your firm certified by SBA as “HUBZone” ? Is your firm certified by SBA as “SDB” ? Yes Yes Yes Date: No No No Exit Date: Title: Is your company certified by a Federal or State agency as a minority owned business enterprise (MBE)? Is your company certified by a Federal or State agency as a woman owned business enterprise (WBE)? Information on CCR (Central Contractor Registration) is available at www.ccr.gov Yes Yes No No Supplier Profile Form/September 2005