UNITED INDEPENDENT SCHOOL DISTRICT
REQUEST FOR CONSULTANT SERVICES
Please complete this form and attach it to the Contract for Professional Services at least two weeks prior to hiring the
consultant. If consultant's fee is more than the maximum authorized amount per day (Bachelors - $1,000, Masters - $1,500,
Doctorate - $2,000), the Superintendent's approval is required below.
Address / City / State / Zip Code
Services to be rendered: ______________________________________________________________________________________
Credentials (attach degree, expertise, etc.): ________________________________________________________________________
Date(s) of Service: __________________________________________________________________________________________
Time/Place of Service: _______________________________________________________________________________________
Audience/Number of Employees/Students to be trained: ______________________________________________________________
Reason for hiring this consultant: ______________________________________________________________________________
Certification of Criminal History Record
Has the Consultant completed a Certification of Criminal History Record Information Form? (726-001A) Yes _____ No _____
If Yes , attach a copy to this form and proceed with request.
If No , request for Consultant Services will not be processed.
Consultant's Fee: $______ per _________ not to exceed $________
Travel Reimbursement (based on UISD guidelines): Yes ____ No ____ Estimated $__________
Additional fees, if any, i.e. materials $________________
Fund/Yr Func. Org. Program Code Local Option Object Sub object
Other Comments: ________________________________________________________________
Originator's Signature Date Campus/Dept. Administrator's Approval Date
Approved __________ Not Approved ___________
Director of Professional Development Date
Approved __________ Not Approved ___________
Ex. Director of Federal Programs Date Approval Needed for Federal Funding Only
Approved __________ Not Approved ___________
Assoc. Supt./Asst. Supt./Ex. Director Date
Approval For Amounts In Excess of Maximum Allowed:
Superintendent's Signature Date
UISD FORM 726-001
UNITED INDEPENDENT SCHOOL DISTRICT
CERTIFICATION OF CRIMINAL HISTORY RECORD INFORMATON
Please have Consultant complete section 1, 2, or 3 of this form and attach to the Request for Consultant Services
form (#726-001). Form is required by Texas Education Code § 22.0834 and by UISD for processing of payment.
Address / City / State / Zip Code
Services to be rendered: ___________________________________________________________
The following scections must be filled out by Consultant
Answer Y for Yes or N for No:
Will employees, including yourself, have continuing duties related to the services
Until it receives further guidance, the District considers “continuing duties” to mean
repetitive work duties rather than a one time appearance or engagement.
Will those employees, including yourself, have direct contact with students?
Until it receives further guidance, the District considers “direct contact” to mean services
that may be performed independently from school district staff involvement. Direct contact
can include chance contact such as performing routine inspections or maintenance; contact
with groups of students during organized activities; or more obvious examples such as
tutoring or therapy.
If either question is answered "no", consultant should complete section 2 of this form.
If answer to both questions is "yes", consultant should complete section 3 of this form.
I agree and understand employees of the company or individuals, including myself, who have
not received the required criminal background check because the above description does not
apply to them/myself will be considered visitors when on school campus and must follow school
district and campus policies related to visitors on school campuses.
Signature of Consultant Date
I, _______________________________________________, certify that all employees,
including myself, of the company that I own, operate, or manage, or myself as an independent
contractor who have continuing duties related to the service to be performed on a United
Independent School District Campus and who also have direct contact with students have
undergone the required criminal history background check or national criminal history record
information review which may include fingerprints and photographs and that no prohibited
contact as described herein was revealed. The District reserves the right to request an actual
Criminal History report.
Signature of Consultant Date
UISD FORM 726-001A
United Independent School District
Certification of Criminal History Record Information
SB 9, passed during the 80th Legislative Session, requires that all Texas public school
districts receive certification from any entity with which it contracts to provide services
that it has obtained a criminal history background check on all employees hired before
January 1, 2008 who (1) have continuing duties related to contracted services; and (2)
have direct contact with students.
The required criminal history record information can be obtained from either of the
A law enforcement or criminal justice agency
A private entity that is a consumer reporting agency governed by the Fair Credit
Reporting Act (15 U.S.C. Section 1681 et seq.)
Although state law provides guidance as to which employees must have a criminal
background check, there is no specific definition or description as to what equals an
employee who (1) has continuing duties related to contracted services; and (2) has direct
contact with students.* The law states that the Commissioner of Education may adopt
rules necessary to implement this requirement; however, at this time none have been
adopted. Therefore, all entities and individuals who contract with the District to perform
services, must complete the UISD Form #726-001A that includes an information sheet
related to the services to be performed and the duties related to those services that
employees will be performing and the type of contact that those employees might have
• Employees who are hired by an entity that contracts with a school district after
January 1, 2008 must submit to a national criminal history record information
review which may include fingerprints and photographs before serving in the
The school district may not allow any employee of the entity or an individual to serve at
the district if information is obtained through this review that the employee has been
convicted of one of the following:
(1) A Title 5 felony offense
(2) An offense requiring the individual to register as a sex offender
(3) An offense under the laws of another state or federal law that is equivalent to a Title 5
felony in the state of Texas or that would require registration in the Texas sex offender
At any time, a school district administrator, including a campus principal or designee,
may request copies of the actual criminal background check or national criminal history
record information review which may include fingerprints and photographs from the
entity or individual who has contracted with the school district or may obtain from any
law enforcement or criminal justice agency all criminal history record information that
relates to an individual described above.
UISD FORM #726-001B
UNITED INDEPENDENT SCHOOL DISTRICT
CONTRACT FOR PROFESSIONAL SERVICES
PROGRAM LOCAL SUB
FUND/YR FUNC. ORG. CODE OPTION OBJECT OBJECT AMOUNT
Pay to: ______________________________________________________________________________
(CITY) (STATE) (ZIP)
(Check will be mailed to payee.)
This contract and agreement is made and entered into by and between the United Independent School District, referred to herein as “District,” and
______________________________referred to herein as “Consultant(s).” The parties have severally and collectively agreed and by the execution
hereof are bound to the mutual obligations and to the performance and accomplishment of the tasks hereinafter described:
Date(s) of Service: _______________________________ Description of Services: ____________________________________
Consultant shall provide professional services, consultation, and expertise to the District for use and benefit of public education in Texas. The
District shall pay to Consultant a fee of $_________ per __________ not to exceed $____________ . Fees will be paid based on invoice(s) sub-
mitted by consultant which should include Date of Service and Description of Services. Travel will _____ or will not _____ be reimbursed.
All travel reimbursements will be based on the District’s travel guidelines provided that itemized receipts are submitted.
Note: This is not a complete contract unless accompanied by an approved “Request for Consultant Services” form and “Certification of Criminal History
Record Information” form.
All information, materials, or products developed pursuant to this contract shall be the property of the District if the information, materials, and
products are specifically developed by Consultant for District, and the District incurs charges for the development of said products Consultant shall
not assert any claims at common law or in equity or establish any claim to statutory copyright in such materials or make any reproduction of said
materials without the prior written permission of the District.
This contract in all its particulars is subject to all Federal and Texas State Laws, rules, and regulations pertaining to the contract project, including
but not limited to Titles VI and VII of the Civil Rights Act of 1964, as amended; and Title IX of the Education Amendments of 1972, as amended;
and recourse to judicial action shall be in the Courts of the State of Texas to the exclusion of all other courts. The district certifies that there is no
conflict of interest in hiring this consultant and that this service could not have been provided by an employee within the district.
If an extension of this Agreement is mutually agreed upon, the parties to this Agreement will execute another Agreement to set the terms and condi-
tions. In the event of termination for cause or for convenience of this Agreement by District or Consultant, compensation shall be prorated on the
basis of hours actually worked and Consultant shall only be entitled to receive just and equitable compensation for any satisfactory work completed
and expenses incurred up to the date of termination. In the event that Consultant is terminated for cause or for convenience, Consultant will be
provided three(3) days notice before being terminated by the District. District or Consultant may terminate this Agreement prior to the commence-
ment of the Consultant Services for cause or for convenience, in which case, Consultant shall not be entitled to any compensation for expenses in-
curred after the termination of contract. Consultant may not assign this contract to a third party without the written consent of the District, Consult-
ant is not an employee of the District, and is not entitled to any benefits. District shall not deduct Federal income taxes, FICA, Social Security, or
an other taxes required to be deducted by an employer, as this is the responsibility of Consultant. Consultant is subject to the policies , directives,
rules, and procedures of the Board of Trustees, Administration and Supervisory Personnel, and is subject to the laws of the State of Texas and of the
United States, now and as may be thereafter in place.
Approved and accepted by Consultant(s)) this ____________ day of ____________________, 20_____.
Consultant(s) Signature: ___________________________ S.S. Number / Employer Identification Number: _____________________.
Approved and accepted by the United Independent School District this ____ day of ______________, 20____Originator’s Signature: _________________________
Signature of Administrator/Principal Date
FOR ACCOUNTING DEPARTMENT USE ONLY
Accounting Department Date
UISD Form 726-002
(Rev. October 2007)
W-9 Request for Taxpayer Give form to the
requester. Do not
Department of the Treasury
Identification Number and Certification send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
See Specific Instructions on page 2.
Business name, if different from above
Print or type
Check appropriate box: Individual/Sole proprietor Corporation Partnership
Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) payee
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 Line 1 to avoid Social security number
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. or
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 Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted. ● An individual who is a U.S. citizen or U.S. resident alien,
● A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number (TIN) ● An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate ● A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701-7).
abandonment of secured property, cancellation of debt, or
Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA.
trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners’ share of income
resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct (or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
2. Certify that you are not subject to backup withholding, or provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on purposes of establishing its U.S. status and avoiding withholding
foreign partners’ share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester’s form if it is following cases:
substantially similar to this Form W-9.
● The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X Form W-9 (Rev. 10-2007)
Form W-9 (Rev. 10-2007) Page 2
● The U.S. grantor or other owner of a grantor trust and not the 4. The IRS tells you that you are subject to backup
trust, and withholding because you did not report all your interest and
● The U.S. trust (other than a grantor trust) and not the dividends on your tax return (for reportable interest and
beneficiaries of the trust. dividends only), or
Foreign person. If you are a foreign person, do not use Form 5. You do not certify to the requester that you are not subject
W-9. Instead, use the appropriate Form W-8 (see Publication to backup withholding under 4 above (for reportable interest and
515, Withholding of Tax on Nonresident Aliens and Foreign dividend accounts opened after 1983 only).
Entities). Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Nonresident alien who becomes a resident alien. Generally, Instructions for the Requester of Form W-9.
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income. Also see Special rules for partnerships on page 1.
However, most tax treaties contain a provision known as a
“saving clause.” Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of Failure to furnish TIN. If you fail to furnish your correct TIN to a
income even after the payee has otherwise become a U.S. requester, you are subject to a penalty of $50 for each such
resident alien for tax purposes. failure unless your failure is due to reasonable cause and not to
If you are a U.S. resident alien who is relying on an exception willful neglect.
contained in the saving clause of a tax treaty to claim an Civil penalty for false information with respect to
exemption from U.S. tax on certain types of income, you must withholding. If you make a false statement with no reasonable
attach a statement to Form W-9 that specifies the following five basis that results in no backup withholding, you are subject to a
items: $500 penalty.
1. The treaty country. Generally, this must be the same treaty Criminal penalty for falsifying information. Willfully falsifying
under which you claimed exemption from tax as a nonresident certifications or affirmations may subject you to criminal
alien. penalties including fines and/or imprisonment.
2. The treaty article addressing the income. Misuse of TINs. If the requester discloses or uses TINs in
3. The article number (or location) in the tax treaty that violation of federal law, the requester may be subject to civil and
contains the saving clause and its exceptions. criminal penalties.
4. The type and amount of income that qualifies for the
exemption from tax. Specific Instructions
5. Sufficient facts to justify the exemption from tax under the Name
terms of the treaty article.
If you are an individual, you must generally enter the name
Example. Article 20 of the U.S.-China income tax treaty allows
shown on your income tax return. However, if you have changed
an exemption from tax for scholarship income received by a
your last name, for instance, due to marriage without informing
Chinese student temporarily present in the United States. Under
the Social Security Administration of the name change, enter
U.S. law, this student will become a resident alien for tax
your first name, the last name shown on your social security
purposes if his or her stay in the United States exceeds 5
card, and your new last name.
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of If the account is in joint names, list first, and then circle, the
Article 20 to continue to apply even after the Chinese student name of the person or entity whose number you entered in Part I
becomes a resident alien of the United States. A Chinese of the form.
student who qualifies for this exception (under paragraph 2 of Sole proprietor. Enter your individual name as shown on your
the first protocol) and is relying on this exception to claim an income tax return on the “Name” line. You may enter your
exemption from tax on his or her scholarship or fellowship business, trade, or “doing business as (DBA)” name on the
income would attach to Form W-9 a statement that includes the “Business name” line.
information described above to support that exemption.
Limited liability company (LLC). Check the “Limited liability
If you are a nonresident alien or a foreign entity not subject to company” box only and enter the appropriate code for the tax
backup withholding, give the requester the appropriate classification (“D” for disregarded entity, “C” for corporation, “P”
completed Form W-8. for partnership) in the space provided.
What is backup withholding? Persons making certain payments For a single-member LLC (including a foreign LLC with a
to you must under certain conditions withhold and pay to the domestic owner) that is disregarded as an entity separate from
IRS 28% of such payments. This is called “backup withholding.” its owner under Regulations section 301.7701-3, enter the
Payments that may be subject to backup withholding include owner’s name on the “Name” line. Enter the LLC’s name on the
interest, tax-exempt interest, dividends, broker and barter “Business name” line.
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate For an LLC classified as a partnership or a corporation, enter
transactions are not subject to backup withholding. the LLC’s name on the “Name” line and any business, trade, or
DBA name on the “Business name” line.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the Other entities. Enter your business name as shown on required
proper certifications, and report all your taxable interest and federal tax documents on the “Name” line. This name should
dividends on your tax return. match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
Payments you receive will be subject to backup name on the “Business name” line.
withholding if: Note. You are requested to check the appropriate box for your
1. You do not furnish your TIN to the requester, status (individual/sole proprietor, corporation, etc.).
2. You do not certify your TIN when required (see the Part II Exempt Payee
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect If you are exempt from backup withholding, enter your name as
TIN, described above and check the appropriate box for your status,
then check the “Exempt payee” box in the line following the
business name, sign and date the form.
Form W-9 (Rev. 10-2007) Page 3
Generally, individuals (including sole proprietors) are not exempt Part I. Taxpayer Identification
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends. Number (TIN)
Note. If you are exempt from backup withholding, you should Enter your TIN in the appropriate box. If you are a resident
still complete this form to avoid possible erroneous backup alien and you do not have and are not eligible to get an SSN,
withholding. your TIN is your IRS individual taxpayer identification number
The following payees are exempt from backup withholding: (ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account If you are a sole proprietor and you have an EIN, you may
satisfies the requirements of section 401(f)(2), enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
2. The United States or any of its agencies or If you are a single-member LLC that is disregarded as an
instrumentalities, entity separate from its owner (see Limited liability company
3. A state, the District of Columbia, a possession of the United (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner
States, or any of their political subdivisions or instrumentalities, has one). Do not enter the disregarded entity’s EIN. If the LLC is
4. A foreign government or any of its political subdivisions, classified as a corporation or partnership, enter the entity’s EIN.
agencies, or instrumentalities, or Note. See the chart on page 4 for further clarification of name
5. An international organization or any of its agencies or and TIN combinations.
instrumentalities. 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
Other payees that may be exempt from backup withholding for a Social Security Card, from your local Social Security
include: Administration office or get this form online at www.ssa.gov. You
6. A corporation, may also get this form by calling 1-800-772-1213. Use Form
7. A foreign central bank of issue, W-7, Application for IRS Individual Taxpayer Identification
8. A dealer in securities or commodities required to register in Number, to apply for an ITIN, or Form SS-4, Application for
the United States, the District of Columbia, or a possession of Employer Identification Number, to apply for an EIN. You can
the United States, apply for an EIN online by accessing the IRS website at
www.irs.gov/businesses and clicking on Employer Identification
9. A futures commission merchant registered with the Number (EIN) under Starting a Business. You can get Forms W-7
Commodity Futures Trading Commission, and SS-4 from the IRS by visiting www.irs.gov or by calling
10. A real estate investment trust, 1-800-TAX-FORM (1-800-829-3676).
11. An entity registered at all times during the tax year under If you are asked to complete Form W-9 but do not have a TIN,
the Investment Company Act of 1940, write “Applied For” in the space for the TIN, sign and date the
form, and give it to the requester. For interest and dividend
12. A common trust fund operated by a bank under section payments, and certain payments made with respect to readily
584(a), tradable instruments, generally you will have 60 days to get a
13. A financial institution, TIN and give it to the requester before you are subject to backup
14. A middleman known in the investment community as a withholding on payments. The 60-day rule does not apply to
nominee or custodian, or other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to
15. A trust exempt from tax under section 664 or described in the requester.
Note. Entering “Applied For” means that you have already
The chart below shows types of payments that may be applied for a TIN or that you intend to apply for one soon.
exempt from backup withholding. The chart applies to the Caution: A disregarded domestic entity that has a foreign owner
exempt payees listed above, 1 through 15. must use the appropriate Form W-8.
IF the payment is for . . . THEN the payment is exempt Part II. Certification
for . . .
To establish to the withholding agent that you are a U.S. person,
Interest and dividend payments All exempt payees except or resident alien, sign Form W-9. You may be requested to sign
for 9 by the withholding agent even if items 1, 4, and 5 below indicate
Broker transactions Exempt payees 1 through 13. otherwise.
Also, a person registered under For a joint account, only the person whose TIN is shown in
the Investment Advisers Act of Part I should sign (when required). Exempt payees, see Exempt
1940 who regularly acts as a Payee on page 2.
broker Signature requirements. Complete the certification as indicated
Barter exchange transactions Exempt payees 1 through 5 in 1 through 5 below.
and patronage dividends 1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
Payments over $600 required Generally, exempt payees
2 during 1983. You must give your correct TIN, but you do not
to be reported and direct 1 through 7 have to sign the certification.
sales over $5,000
2. Interest, dividend, broker, and barter exchange
1 accounts opened after 1983 and broker accounts considered
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2 inactive during 1983. You must sign the certification or backup
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
withholding will apply. If you are subject to backup withholding
corporation) and reportable on Form 1099-MISC are not exempt from and you are merely providing your correct TIN to the requester,
backup withholding: medical and health care payments, attorneys’ fees, and you must cross out item 2 in the certification before signing the
payments for services paid by a federal executive agency. form.
Form W-9 (Rev. 10-2007) Page 4
3. Real estate transactions. You must sign the certification. Secure Your Tax Records from Identity Theft
You may cross out item 2 of the certification.
Identity theft occurs when someone uses your personal
4. Other payments. You must give your correct TIN, but you information such as your name, social security number (SSN), or
do not have to sign the certification unless you have been other identifying information, without your permission, to commit
notified that you have previously given an incorrect TIN. “Other fraud or other crimes. An identity thief may use your SSN to get
payments” include payments made in the course of the a job or may file a tax return using your SSN to receive a refund.
requester’s trade or business for rents, royalties, goods (other
than bills for merchandise), medical and health care services To reduce your risk:
(including payments to corporations), payments to a ● Protect your SSN,
nonemployee for services, payments to certain fishing boat crew ● Ensure your employer is protecting your SSN, and
members and fishermen, and gross proceeds paid to attorneys ● Be careful when choosing a tax preparer.
(including payments to corporations).
Call the IRS at 1-800-829-1040 if you think your identity has
5. Mortgage interest paid by you, acquisition or been used inappropriately for tax purposes.
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA, Victims of identity theft who are experiencing economic harm
Coverdell ESA, Archer MSA or HSA contributions or or a system problem, or are seeking help in resolving tax
distributions, and pension distributions. You must give your problems that have not been resolved through normal channels,
correct TIN, but you do not have to sign the certification. may be eligible for Taxpayer Advocate Service (TAS) assistance.
You can reach TAS by calling the TAS toll-free case intake line
at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
What Name and Number To Give the Requester
Protect yourself from suspicious emails or phishing
For this type of account: Give name and SSN of: schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
1. Individual The individual
websites. The most common act is sending an email to a user
2. Two or more individuals (joint The actual owner of the account or,
account) if combined funds, the first
falsely claiming to be an established legitimate enterprise in an
individual on the account
attempt to scam the user into surrendering private information
3. Custodian account of a minor The minor
2 that will be used for identity theft.
(Uniform Gift to Minors Act)
The IRS does not initiate contacts with taxpayers via emails.
4. a. The usual revocable savings The grantor-trustee Also, the IRS does not request personal detailed information
trust (grantor is also trustee) through email or ask taxpayers for the PIN numbers, passwords,
b. So-called trust account that is The actual owner or similar secret access information for their credit card, bank, or
not a legal or valid trust under other financial accounts.
5. Sole proprietorship or disregarded The owner
If you receive an unsolicited email claiming to be from the IRS,
entity owned by an individual forward this message to email@example.com. You may also report
Give name and EIN of:
misuse of the IRS name, logo, or other IRS personal property to
For this type of account:
the Treasury Inspector General for Tax Administration at
6. Disregarded entity not owned by an The owner 1-800-366-4484. You can forward suspicious emails to the
individual Federal Trade Commission at: firstname.lastname@example.org or contact them at
7. A valid trust, estate, or pension trust Legal entity www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).
8. Corporate or LLC electing The corporation
corporate status on Form 8832 Visit the IRS website at www.irs.gov to learn more about
9. Association, club, religious, The organization identity theft and how to reduce your risk.
charitable, educational, or other
10. Partnership or multi-member LLC The partnership
11. A broker or registered nominee The broker or nominee
12. Account with the Department of The public entity
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
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.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business or “DBA”
name on the second name line. You may use either your SSN or EIN (if you have one),
but the IRS encourages you to use your SSN.
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. If no name is circled when more than one name is listed,
the number will be considered to be that of the first name listed.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax 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. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session. OFFICE USE ONLY
This questionnaire is being filed in accordance with Chapter 176, Local Government Code Date Received
by a person who has a business relationship as defined by Section 176.001(1-a) with a local
governmental entity and the person meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental
entity not later than the 7th business day after the date the person becomes aware of facts
that require the statement to be filed. See Section 176.006, Local Government Code.
A person commits an offense if the person knowingly violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
1 Name of person who has a business relationship with local governmental entity.
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not
later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
Name of local government officer with whom filer has employment or business relationship.
Name of Officer
This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an
employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional
pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment
income, from the filer of the questionnaire?
B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the
direction of the local government officer named in this section AND the taxable income is not received from the local
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local
government officer serves as an officer or director, or holds an ownership of 10 percent or more?
D. Describe each employment or business relationship with the local government officer named in this section.
Signature of person doing business with the governmental entity Date