City of Cedar Rapids Vendor Registration Packet Transmittal Form The Vendor Registration Packet includes information about the terms and conditions of doing business with the City of Cedar Rapids and the forms necessary to register a business. Please complete the enclosed forms and return to the City Finance Department (address and contact information below). The forms may be returned by US mail, email or fax. Documents included with this packet: Transmittal Form Doing Business with the City of Cedar Rapids Vendor Registration Form Conflict of Interest Statement ACH Authorization Agreement W-9 Form Use the following checklist to make sure required forms are returned and information is complete: REQUIRED DOCUMENTS Doing Business with the City Vendor Registration Form Conflict of Interest Statement Is the form notarized? W-9 Form - Do not return instructions Is the form signed? OPTIONAL DOCUMENT ACH Authorization Agreement Is a voided check attached? Forms should be typed or printed for legibility. Vendor Registration Contact and Address Information: City of Cedar Rapids Finance Department – Accounts Payable Division 3851 River Ridge Dr NE Cedar Rapids, IA 52402 Email: firstname.lastname@example.org Fax: 319-286-5130 Phone: 319-286-5013 Vendor Registration Packet – Transmittal Form Updated 02-28-2011 City of Cedar Rapids Doing Business with the City CITY PURCHASING Vendors can find information regarding City of Cedar Rapids purchasing on the City’s web site at www.cedar- rapids.org/government/departments/purchasing. The site contains information on policies and procedures, contacts and addresses, goods and services the City purchases, and bid opportunities. City of Cedar Rapids Finance Department – Purchasing Services Division 3851 River Ridge Dr NE Cedar Rapids, IA 52402 Fax: 319-286-5130 Phone: 319-286-5021 Primary Contact: Judy Lehman, Purchasing Services Manager Initial: PURCHASING METHODS City buyers and purchasing agents are required to solicit quotations, bids, or proposals for items costing $1,000 and greater to obtain the quality of materials and/or services consistent with the city’s needs, in a timely manner and at the best value. Purchases will be made using sound purchasing judgment without favor or prejudice, to ensure that public money is spent efficiently and effectively. Potential vendors will be given an opportunity to provide quotations, bids or proposals and will be treated fairly in the process. A listing of bid and proposal opportunities can be found at www.cedar- rapids.org/government/departments/purchasing/. Initial: PURCHASE ORDER REQUIREMENT City buyers are required to provide vendors with an authorized purchase order on City form CCR.PO.100 or CCR.PO.101 for all purchases made on account or for all purchases equal to or greater than $1,000 when using the City’s procurement card. Vendor invoices must include the purchase order number when presented to the City for payment. Initial: Doing Business with the City – 02/28/2011 Page 1 of 5 City of Cedar Rapids Doing Business with the City SALES VISITS Sales representatives are a valuable source of information in obtaining bids, specifications, state of the art advancements or product improvements, and in resolving problems in delivery. It is recommended that as a professional courtesy, sales representatives call (319) 286-5021 for an appointment rather than engaging in unannounced visits. Initial: GRATUITIES OR GIFTS Do not offer discounts on goods and/or services to employees of the City making personal purchases when the discounts are not offered to the general public. In order to maintain integrity and to continue to foster ethical and equal opportunities among the business community, City employees and City departments are prohibited from accepting any gratuities, in any form, from any supplier or potential supplier, either directly or indirectly. Please refer to Chapter 68B.22 of the Code of Iowa, Gifts Accepted or Received, for the specific language. The City of Cedar Rapids respectfully requests vendors not send gifts such as calendars, candy, flowers, etc. at Christmas or other special occasions. Gifts received will be returned to the vendor. Initial: BUY LOCAL PROGRAM The City of Cedar Rapids has adopted a Buy Local Program for the procurement of goods and/or services by competitive bid. The City of Cedar Rapids shall give preference to a responsive bid from a business located within Linn County, Iowa, over an acceptable low bid submitted by a business located outside of Linn County, Iowa. Visit www.cedar-rapids.org/government/departments/purchasing for information on the City’s Buy Local Program, access the buy local certification form, and to view a list of certified local businesses. Certified local businesses shall be given a percentage preference based on bid/quote/RFP cost. Questions regarding the Buy Local Program should be emailed to email@example.com, or contact Purchasing Services at 319-286-5021. Preference shall be applied in percentage of dollars of low quotes and bids or by percentage of total available points for proposal requests. Percentages are as follows: • 10% for bids less than $25,000 • 5% for bids equal to or greater than $25,000 but less than $200,000 • 1% for bids equal to or greater than $200,000 Local preference is applicable only to goods and services purchased without the assistance of federal, state or county grants or funds or pursuant to the competitive laws of the State of Iowa. Initial: Doing Business with the City – 02/28/2011 Page 2 of 5 City of Cedar Rapids Doing Business with the City CITY ACCOUNTS Vendors shall establish City Accounts with the billing name, address and contact information given below. Vendors should not create multiple accounts for the City of Cedar Rapids. Vendors shall either mail original invoices to the physical address, send invoices electronically to the email address, or fax invoices to the fax number. The City reserves the right to reject any invoice not sent to the locations below . City of Cedar Rapids Finance Department – Accounts Payable Division 3851 River Ridge Dr NE Cedar Rapids, IA 52402 Fax: 319-286-5130 Phone: 319-286-5013 Email: firstname.lastname@example.org Primary Contact: Gaye Roberts, Vendor Account Specialist Phone: 319-286-5013 Email email@example.com Secondary Contact: Alyson Eadie, Accounts Payable Administrator Phone: 319-286-5096 Email: firstname.lastname@example.org Initial: VENDOR REGISTRATION Businesses can find a Vendor Registration Packet available on the City’s web site. Included in the Registration Packet are the required forms a business must submit to be a registered vendor for the City. The required forms include a completed Vendor Registration Form, IRS W-9 and a Conflict of Interest Statement. Only registered vendors are eligible to receive purchase orders for goods or services. Payments are not issued to businesses without being fully registered. Businesses who are not registered vendors should include a completed Vendor Registration Packet when submitting a quote/bid/RFP to the City. The completed forms may also be submitted to the City Finance Department – Accounts Payable Division (see CITY ACCOUNTS section). Registered vendors will not automatically receive requests for bids, quotes or proposals. See the CITY PURCHASING and PURCHASING METHODS sections on page 1 for bid information. Initial: Doing Business with the City – 02/28/2011 Page 3 of 5 City of Cedar Rapids Doing Business with the City BILLING THE CITY Invoices, statements, past due notices, account balance issues, etc. should be sent to the contact information listed under the CITY ACCOUNTS section. Using the proper address and contact information will assist the City in providing timely payment according to payment terms. The City will adjust due dates according to the date the invoice is received by Accounts Payable when the invoice is sent to an address other than City Finance Department – Accounts Payable Division (see CITY ACCOUNTS section). Terms of payment are stated on the purchase order or in the contract. Unless indicated otherwise, the term of payment is Net 30 days. Initial: INVOICE CONTENT Vendor invoices shall clearly state the business name, physical address, remittance name and address, invoice date and payment terms. The invoices shall also provide detailed information as applicable to the goods and services purchased to include, but not limited to, purchase date, ship date, unit prices and quantities, detailed description of items and extended totals. All invoices shall include the City’s purchase order number. Contract Work: The City shall not be billed for work performed prior to the effective date of the contract. Vendors shall obtain an authorized purchase order in addition to the signed contract. Invoices submitted under certain contract types such as a time and materials contract will require additional documentation including, but not limited to, timesheets and copies of receipts for materials purchased to support the invoice charges. Invoices shall state the terms of payment negotiated in the contract. All contract invoices shall include the contract number assigned by the Finance Department - Accounts Payable Division. Invoices received without adequate information and/or proper documentation and/or with computation errors will be deemed unacceptable and returned to the vendor for correction. Initial: SALES TAX EXEMPTION The City of Cedar Rapids is a municipality and claims exemption from Iowa sales/use tax as a political subdivision of the State of Iowa. A sales tax exemption certificate will be provided to registered vendors. Vendors awarded a contract related to a public improvement construction project may submit a request to the Accounts Payable Division to register the contract with the Iowa Department of Revenue. Sales tax exemption certificates will be issued to the contractor and subcontractors for use in purchasing materials in performing the contract. Initial: Doing Business with the City – 02/28/2011 Page 4 of 5 City of Cedar Rapids Doing Business with the City PAYMENT Payments are issued to vendors by check, ACH Deposit or MasterCard credit card (see Procurement Card Program below). Check and ACH payments are approved by the City Council at regularly scheduled Council meetings. Council meetings are generally held on the 2nd and 4th Tuesday of each month. Checks are mailed on the Thursday following the Council meeting. ACH payments are settled on the due date or the last business day prior to the due date. Questions about City checks or ACH payments may be directed to 319-286-5013 or emailed to email@example.com. NOTE: Vendors desiring to pick up checks from the Accounts Payable Division must make arrangements in advance by calling 319-286-5013. The individual picking up the check must present a statement signed by an authorized representative of the company and a driver’s license to confirm identification. All payments approved by the City Council are published in the Cedar Rapids Gazette two weeks following the Council meeting. Detailed information on the City’s cash disbursements can be found at the Cedar Rapids Public Library and on the Finance web site at www.cedar-rapids.org/government/departments/finance/financialreporting. Initial: PROCUREMENT CARD PROGRAM Authorized City buyers are issued a MasterCard credit card to make small dollar purchases. The City’s credit cards are restricted from certain establishments based on the vendor’s merchant category code (MCC) and by dollar limits assigned to the card. Vendors shall verify the identity of the cardholder when purchases are made in person by asking the cardholder to present his or her City badge. When purchases are not made in person, vendors shall use all prudent methods to verify the individual authorizing payment is the individual named on the credit card. Purchases equal to or greater than $1,000 require the City buyers to present authorized purchase orders (see PURCHASE ORDER REQUIREMENT section) when purchasing using the credit card. The vendor shall not split a purchase to circumvent the credit card’s transaction limit or the purchase order requirement. A detailed receipt/invoice shall be given to document the credit card charge. The receipt/invoice shall include all the required information as stated in the section titled Invoice Content. Initial: I, , as an authorized representative of (Company) have read and initialed each section of this document to show that I understand and agree to the terms and conditions of doing business with the City of Cedar Rapids. Signature Title Date Internal Use Only Vendor ID: Vendor Location ID: Updated by: Doing Business with the City – 02/28/2011 Page 5 of 5 City of Cedar Rapids Vendor Registration Form Please Print or Type the requested information. Name and Address Information* Individual/Company/Corporate Name: DBA (name as it appears on the invoice): Remittance Address: (Street, City, State & Zip Code) Physical location of business: (Street, City, State & Zip Code) Name of county where business physically resides: Briefly describe the services or materials provided: Website Address: Are you a minority or disadvantaged owned concern (at least 51% owned, Yes No controlled, and actively managed by one or more minorities, or if a publicly- owned concern, at least 51% of the stock owned by one or more minorities) Are you a woman owned concern (at least 51% owned, controlled, and Yes No actively managed by one or more women, or if a publicly-owned concern, at least 51% of the stock owned by one or more women) Owner/President Name: Accounts Receivable Contact Information Contact name(s): Phone No.: Fax No.: Email: General Payment Terms Prompt Payment Discount: Yes % if paid within days No Refer to invoice for discount terms Payment Terms (required): Payment Methods: MasterCard credit card payment accepted ACH payments accepted (ACH Authorization Agreement required) Check only Signed: Print Name & Title: Date: * P lease feel free to attach additional contact and address inform ation if applicable. Internal Use Only Vendor ID: Vendor Location ID: Updated by: Vendor Registration Form Updated 02/22/11 City of Cedar Rapids Conflict of Interest Statement Name of Business: List the names of any of your officers, employees, stock holders owning more than 5% of shares, or any individuals with a financial interest in your business that are employed, serve as elected officials, or are appointed as board members in any capacity by the City of Cedar Rapids. Name Position in Company (1) (2) (3) (4) (5) Attach a separate list if more than five individuals qualify. I, , certify that the information supplied herein is correct and that neither (name of business) nor any person or concern in any connection with (name of business) as a principal or officer is now debarred or otherwise declared ineligible by any public agency from bidding for furnishing materials, supplies or services to any public agency thereof. Signature Title Date Subscribed and sworn to this _ _ day of , 20 before the undersigned Notary Public. NOTARY PUBLIC, STATE OF IOWA Internal Use Only Vendor ID: Vendor Location ID: Updated by: Vendor Registration – Conflict of Interest Statement Updated 01/07/2010 City of Cedar Rapids ACH Authorization Agreement Please complete the information below and ATTACH A VOIDED CHECK. Business Name: Address: Email: Phone: SSN or Business EIN: Bank Name: Bank Routing No.: Account No.: Account Type: (check one) Checking Savings I, , hereby authorize and request the City of Cedar Rapids to initiate deposits to the account with the financial institution named above. This authority is to remain in effect until (name of business) or the City of Cedar Rapids terminates the agreement. A written request for termination must be provided by the business five (5) business days prior to the effective date of termination. The City of Cedar Rapids may terminate this agreement at any time. Signature Title Date Attach voided check here. A deposit slip is not an acceptable alternative. Internal Use Only Vendor ID: Vendor Location ID: Updated by: ACH Authorization Agreement Updated 01/07/2010 Form W-9 Request for Taxpayer Give Form to the requester. Do not (Rev. January 2011) Department of the Treasury Identification Number and Certification send to the IRS. Internal Revenue Service Name (as shown on your income tax return) Business name/disregarded entity name, if different from above See Specific Instructions on page 2. Check appropriate box for federal tax classification (required): Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Print or type Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶ Other (see instructions) ▶ Address (number, street, and apt. or suite no.) Requester’s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line Social security number to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. 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 4 for guidelines on whose Employer identification number number to enter. – Part II 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). 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. See the instructions on page 4. Sign Signature of Here U.S. person ▶ Date ▶ General Instructions Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar Section references are to the Internal Revenue Code unless otherwise to this Form W-9. noted. Definition of a U.S. person. For federal tax purposes, you are Purpose of Form considered a U.S. person if you are: A person who is required to file an information return with the IRS must • An individual who is a U.S. citizen or U.S. resident alien, obtain your correct taxpayer identification number (TIN) to report, for • A partnership, corporation, company, or association created or example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the laws of the United States, you paid, acquisition or abandonment of secured property, cancellation • An estate (other than a foreign estate), or of debt, or contributions you made to an IRA. • A domestic trust (as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the Special rules for partnerships. Partnerships that conduct a trade or requester) and, when applicable, to: business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. 1. Certify that the TIN you are giving is correct (or you are waiting for a Further, in certain cases where a Form W-9 has not been received, a number to be issued), partnership is required to presume that a partner is a foreign person, 2. Certify that you are not subject to backup withholding, or and pay the withholding tax. Therefore, if you are a U.S. person that is a 3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W-9 to the partnership to establish your U.S. allocable share of any partnership income from a U.S. trade or business status and avoid withholding on your share of partnership income. is not subject to the withholding tax on foreign partners’ share of effectively connected income. Cat. No. 10231X Form W-9 (Rev. 1-2011) Form W-9 (Rev. 1-2011) Page 2 The person who gives Form W-9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding. establishing its U.S. status and avoiding withholding on its allocable See the instructions below and the separate Instructions for the share of net income from the partnership conducting a trade or business Requester of Form W-9. in the United States is in the following cases: Also see Special rules for partnerships on page 1. • The U.S. owner of a disregarded entity and not the entity, Updating Your Information • The U.S. grantor or other owner of a grantor trust and not the trust, and You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee • The U.S. trust (other than a grantor trust) and not the beneficiaries of and anticipate receiving reportable payments in the future from this the trust. person. For example, you may need to provide updated information if Foreign person. If you are a foreign person, do not use Form W-9. you are a C corporation that elects to be an S corporation, or if you no Instead, use the appropriate Form W-8 (see Publication 515, longer are tax exempt. In addition, you must furnish a new Form W-9 if Withholding of Tax on Nonresident Aliens and Foreign Entities). the name or TIN changes for the account, for example, if the grantor of a Nonresident alien who becomes a resident alien. Generally, only a grantor trust dies. nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax Penalties treaties contain a provision known as a “saving clause.” Exceptions Failure to furnish TIN. If you fail to furnish your correct TIN to a specified in the saving clause may permit an exemption from tax to requester, you are subject to a penalty of $50 for each such failure continue for certain types of income even after the payee has otherwise unless your failure is due to reasonable cause and not to willful neglect. become a U.S. resident alien for tax purposes. Civil penalty for false information with respect to withholding. If you If you are a U.S. resident alien who is relying on an exception make a false statement with no reasonable basis that results in no contained in the saving clause of a tax treaty to claim an exemption backup withholding, you are subject to a $500 penalty. from U.S. tax on certain types of income, you must attach a statement Criminal penalty for falsifying information. Willfully falsifying to Form W-9 that specifies the following five items: certifications or affirmations may subject you to criminal penalties 1. The treaty country. Generally, this must be the same treaty under including fines and/or imprisonment. which you claimed exemption from tax as a nonresident alien. Misuse of TINs. If the requester discloses or uses TINs in violation of 2. The treaty article addressing the income. federal law, the requester may be subject to civil and criminal penalties. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. Specific Instructions 4. The type and amount of income that qualifies for the exemption from tax. Name 5. Sufficient facts to justify the exemption from tax under the terms of If you are an individual, you must generally enter the name shown on the treaty article. your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Example. Article 20 of the U.S.-China income tax treaty allows an Administration of the name change, enter your first name, the last name exemption from tax for scholarship income received by a Chinese shown on your social security card, and your new last name. student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in If the account is in joint names, list first, and then circle, the name of the United States exceeds 5 calendar years. However, paragraph 2 of the person or entity whose number you entered in Part I of the form. the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows Sole proprietor. Enter your individual name as shown on your income the provisions of Article 20 to continue to apply even after the Chinese tax return on the “Name” line. You may enter your business, trade, or student becomes a resident alien of the United States. A Chinese “doing business as (DBA)” name on the “Business name/disregarded student who qualifies for this exception (under paragraph 2 of the first entity name” line. protocol) and is relying on this exception to claim an exemption from tax Partnership, C Corporation, or S Corporation. Enter the entity's name on his or her scholarship or fellowship income would attach to Form on the “Name” line and any business, trade, or “doing business as W-9 a statement that includes the information described above to (DBA) name” on the “Business name/disregarded entity name” line. support that exemption. Disregarded entity. Enter the owner's name on the “Name” line. The If you are a nonresident alien or a foreign entity not subject to backup name of the entity entered on the “Name” line should never be a withholding, give the requester the appropriate completed Form W-8. disregarded entity. The name on the “Name” line must be the name What is backup withholding? Persons making certain payments to you shown on the income tax return on which the income will be reported. must under certain conditions withhold and pay to the IRS a percentage For example, if a foreign LLC that is treated as a disregarded entity for of such payments. This is called “backup withholding.” Payments that U.S. federal tax purposes has a domestic owner, the domestic owner's may be subject to backup withholding include interest, tax-exempt name is required to be provided on the “Name” line. If the direct owner interest, dividends, broker and barter exchange transactions, rents, of the entity is also a disregarded entity, enter the first owner that is not royalties, nonemployee pay, and certain payments from fishing boat disregarded for federal tax purposes. Enter the disregarded entity's operators. Real estate transactions are not subject to backup name on the “Business name/disregarded entity name” line. If the owner withholding. of the disregarded entity is a foreign person, you must complete an You will not be subject to backup withholding on payments you appropriate Form W-8. receive if you give the requester your correct TIN, make the proper Note. Check the appropriate box for the federal tax classification of the certifications, and report all your taxable interest and dividends on your person whose name is entered on the “Name” line (Individual/sole tax return. proprietor, Partnership, C Corporation, S Corporation, Trust/estate). Payments you receive will be subject to backup Limited Liability Company (LLC). If the person identified on the withholding if: “Name” line is an LLC, check the “Limited liability company” box only and enter the appropriate code for the tax classification in the space 1. You do not furnish your TIN to the requester, provided. If you are an LLC that is treated as a partnership for federal 2. You do not certify your TIN when required (see the Part II tax purposes, enter “P” for partnership. If you are an LLC that has filed a instructions on page 3 for details), Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for 3. The IRS tells the requester that you furnished an incorrect TIN, C corporation or “S” for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation 4. The IRS tells you that you are subject to backup withholding section 301.7701-3 (except for employment and excise tax), do not because you did not report all your interest and dividends on your tax check the LLC box unless the owner of the LLC (required to be return (for reportable interest and dividends only), or identified on the “Name” line) is another LLC that is not disregarded for 5. You do not certify to the requester that you are not subject to federal tax purposes. If the LLC is disregarded as an entity separate backup withholding under 4 above (for reportable interest and dividend from its owner, enter the appropriate tax classification of the owner accounts opened after 1983 only). identified on the “Name” line. Form W-9 (Rev. 1-2011) Page 3 Other entities. Enter your business name as shown on required federal Part I. Taxpayer Identification Number (TIN) tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You Enter your TIN in the appropriate box. If you are a resident alien and may enter any business, trade, or DBA name on the “Business name/ you do not have and are not eligible to get an SSN, your TIN is your IRS disregarded entity name” line. individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN Exempt Payee below. If you are exempt from backup withholding, enter your name as If you are a sole proprietor and you have an EIN, you may enter either described above and check the appropriate box for your status, then your SSN or EIN. However, the IRS prefers that you use your SSN. check the “Exempt payee” box in the line following the “Business name/ If you are a single-member LLC that is disregarded as an entity disregarded entity name,” sign and date the form. separate from its owner (see Limited Liability Company (LLC) on page 2), Generally, individuals (including sole proprietors) are not exempt from enter the owner’s SSN (or EIN, if the owner has one). Do not enter the backup withholding. Corporations are exempt from backup withholding disregarded entity’s EIN. If the LLC is classified as a corporation or for certain payments, such as interest and dividends. partnership, enter the entity’s EIN. Note. If you are exempt from backup withholding, you should still Note. See the chart on page 4 for further clarification of name and TIN complete this form to avoid possible erroneous backup withholding. combinations. The following payees are exempt from backup withholding: How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security 1. An organization exempt from tax under section 501(a), any IRA, or a Card, from your local Social Security Administration office or get this custodial account under section 403(b)(7) if the account satisfies the form online at www.ssa.gov. You may also get this form by calling requirements of section 401(f)(2), 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer 2. The United States or any of its agencies or instrumentalities, Identification Number, to apply for an ITIN, or Form SS-4, Application for 3. A state, the District of Columbia, a possession of the United States, Employer Identification Number, to apply for an EIN. You can apply for or any of their political subdivisions or instrumentalities, an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a 4. A foreign government or any of its political subdivisions, agencies, Business. You can get Forms W-7 and SS-4 from the IRS by visiting or instrumentalities, or IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676). 5. An international organization or any of its agencies or If you are asked to complete Form W-9 but do not have a TIN, write instrumentalities. “Applied For” in the space for the TIN, sign and date the form, and give Other payees that may be exempt from backup withholding include: it to the requester. For interest and dividend payments, and certain 6. A corporation, payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you 7. A foreign central bank of issue, are subject to backup withholding on payments. The 60-day rule does 8. A dealer in securities or commodities required to register in the not apply to other types of payments. You will be subject to backup United States, the District of Columbia, or a possession of the United withholding on all such payments until you provide your TIN to the States, requester. 9. A futures commission merchant registered with the Commodity Note. Entering “Applied For” means that you have already applied for a Futures Trading Commission, TIN or that you intend to apply for one soon. 10. A real estate investment trust, Caution: A disregarded domestic entity that has a foreign owner must 11. An entity registered at all times during the tax year under the use the appropriate Form W-8. Investment Company Act of 1940, Part II. Certification 12. A common trust fund operated by a bank under section 584(a), To establish to the withholding agent that you are a U.S. person, or 13. A financial institution, resident alien, sign Form W-9. You may be requested to sign by the 14. A middleman known in the investment community as a nominee or withholding agent even if item 1, below, and items 4 and 5 on page 4 custodian, or indicate otherwise. 15. A trust exempt from tax under section 664 or described in section For a joint account, only the person whose TIN is shown in Part I 4947. should sign (when required). In the case of a disregarded entity, the person identified on the “Name” line must sign. Exempt payees, see The following chart shows types of payments that may be exempt Exempt Payee on page 3. from backup withholding. The chart applies to the exempt payees listed above, 1 through 15. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4. IF the payment is for . . . THEN the payment is exempt 1. Interest, dividend, and barter exchange accounts opened for . . . before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the Interest and dividend payments All exempt payees except certification. for 9 2. Interest, dividend, broker, and barter exchange accounts Broker transactions Exempt payees 1 through 5 and 7 opened after 1983 and broker accounts considered inactive during through 13. Also, C corporations. 1983. You must sign the certification or backup withholding will apply. If Barter exchange transactions and Exempt payees 1 through 5 you are subject to backup withholding and you are merely providing patronage dividends your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. Payments over $600 required to be Generally, exempt payees 3. Real estate transactions. You must sign the certification. You may reported and direct sales over 1 through 7 2 cross out item 2 of the certification. 1 $5,000 1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency. Form W-9 (Rev. 1-2011) Page 4 4. Other payments. You must give your correct TIN, but you do not Note. If no name is circled when more than one name is listed, the have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed. have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for Secure Your Tax Records from Identity Theft rents, royalties, goods (other than bills for merchandise), medical and Identity theft occurs when someone uses your personal information health care services (including payments to corporations), payments to such as your name, social security number (SSN), or other identifying a nonemployee for services, payments to certain fishing boat crew information, without your permission, to commit fraud or other crimes. members and fishermen, and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax return (including payments to corporations). using your SSN to receive a refund. 5. Mortgage interest paid by you, acquisition or abandonment of To reduce your risk: secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or • Protect your SSN, HSA contributions or distributions, and pension distributions. You • Ensure your employer is protecting your SSN, and must give your correct TIN, but you do not have to sign the certification. • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a What Name and Number To Give the Requester notice from the IRS, respond right away to the name and phone number For this type of account: Give name and SSN of: printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you 1. Individual The individual think you are at risk due to a lost or stolen purse or wallet, questionable 2. Two or more individuals (joint The actual owner of the account or, credit card activity or credit report, contact the IRS Identity Theft Hotline account) if combined funds, the first 1 at 1-800-908-4490 or submit Form 14039. individual on the account 3. Custodian account of a minor 2 For more information, see Publication 4535, Identity Theft Prevention The minor (Uniform Gift to Minors Act) and Victim Assistance. 4. a. The usual revocable savings The grantor-trustee 1 Victims of identity theft who are experiencing economic harm or a trust (grantor is also trustee) system problem, or are seeking help in resolving tax problems that have b. So-called trust account that is The actual owner 1 not been resolved through normal channels, may be eligible for not a legal or valid trust under Taxpayer Advocate Service (TAS) assistance. You can reach TAS by state law calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 3 5. Sole proprietorship or disregarded The owner 1-800-829-4059. entity owned by an individual The grantor* Protect yourself from suspicious emails or phishing schemes. 6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Phishing is the creation and use of email and websites designed to Regulation section 1.671-4(b)(2)(i)(A)) mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established For this type of account: Give name and EIN of: legitimate enterprise in an attempt to scam the user into surrendering 7. Disregarded entity not owned by an The owner private information that will be used for identity theft. individual 8. A valid trust, estate, or pension trust Legal entity 4 The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask 9. Corporation or LLC electing The corporation corporate status on Form 8832 or taxpayers for the PIN numbers, passwords, or similar secret access Form 2553 information for their credit card, bank, or other financial accounts. 10. Association, club, religious, The organization If you receive an unsolicited email claiming to be from the IRS, charitable, educational, or other forward this message to firstname.lastname@example.org. You may also report misuse tax-exempt organization of the IRS name, logo, or other IRS property to the Treasury Inspector 11. Partnership or multi-member LLC The partnership General for Tax Administration at 1-800-366-4484. You can forward 12. A broker or registered nominee The broker or nominee suspicious emails to the Federal Trade Commission at: email@example.com 13. Account with the Department of The public entity or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT Agriculture in the name of a public (1-877-438-4338). entity (such as a state or local Visit IRS.gov to learn more about identity theft and how to reduce government, school district, or your risk. prison) that receives agricultural program payments 14. Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671-4(b)(2)(i)(B)) 1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. 2 Circle the minor’s name and furnish the minor’s SSN. 3 You must show your individual name and you may also enter your business or “DBA” name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1. *Note. Grantor also must provide a Form W-9 to trustee of trust. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
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