State of Montana SW9 (12/2014) DO NOT SEND TO THE IRS Substitute W-9 Request for Taxpayer Identification Number and Certification Please see attachment or reverse for complete instructions. Legal Name: (as shown on income tax return) If Sole Entity Designation (check only one designated type) Proprietorship, enter your Last, First, MI Corporation S-Corporation or C-Corporation Do you provide medical services: Yes or No Trade Name: (If doing business as (DBA) or enter business Individual name of Sole Proprietorship) Sole Proprietorship Single-Member LLC Partnership Primary Address: (as entered with IRS) PO Box or Number LLC (for Federal tax purposes taxed as) and Street, City, State, ZIP S-Corp, C-Corp, or Partnership Estate/Trust Other: Remit Address: (where payment should be mailed if Organization Exempt from Tax different from Primary address) PO Box or Number and (Under Section 501 (a)(b)(c)(d)(e)) Street, City, ZIP Governmental Entity Exemptions : Requesters Address: Department of (codes apply only to certain entities, not individuals; see instructions) PO Box Exempt payee code (if any): Exemption from FATCA reporting code (if any): (applies to accounts maintained outside the U.S.) Taxpayer Identification Number (TIN) (Provide Only One) (If sole proprietorship provide FEIN, if applicable) Social Security Number: Employer Identification No: Certification: Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification number, AND 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 back withholding, AND I am a U.S. citizen or other U.S. person (including a US Resident Alien) AND, The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Printed Name: Title: Telephone: Signature: Date: Optional Direct Deposit Information (used at agency discretion) (Must provide a voided check. No Direct Deposit Slips Accepted)
State of Montana SW9 (12/2014) Substitute W-9 DO NOT SEND TO THE IRS Request for Taxpayer Identification Number and Certification Please see attachment or reverse for complete instructions. Legal Name: (as shown on income tax return) If Sole Proprietorship, enter your Last, First, MI Entity Designation (check only one designated type) Corporation S-Corporation or C-Corporation Do you provide medical services: Yes or No Individual Sole Proprietorship Single-Member LLC Partnership LLC (for Federal tax purposes taxed as) S-Corp, C-Corp, or Partnership Estate/Trust Other: Organization Exempt from Tax (Under Section 501 (a)(b)(c)(d)(e)) Governmental Entity Trade Name: (If doing business as (DBA) or enter business name of Sole Proprietorship) Primary Address: (as entered with IRS) PO Box or Number and Street, City, State, ZIP Remit Address: (where payment should be mailed if different from Primary address) PO Box or Number and Street, City, ZIP Exemptions : (codes apply only to certain entities, not individuals; see instructions) Exempt payee code (if any): Exemption from FATCA reporting code (if any): (applies to accounts maintained outside the U.S.) Requesters Address: Department of PO Box Taxpayer Identification Number (TIN) (Provide Only One) (If sole proprietorship provide FEIN, if applicable) Social Security Number: Employer Identification No: Certification: Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification number, AND 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 back withholding, AND I am a U.S. citizen or other U.S. person (including a US Resident Alien) AND, The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Printed Name: Title: Telephone: Signature: Date: Optional Direct Deposit Information (used at agency discretion) (Must provide a voided check. No Direct Deposit Slips Accepted)
W-9%20UPDATED%20March%202015.docx