University of South Florida

Purchasing & Financial Services

Request for Taxpayer Identification and Certification

(Substitute for IRS Form W-9)

Instructions:

  1. Use this form only if you are a U.S. person (including U.S. resident aliens). If you are a foreign person, use the appropriate Form W-8.
  2. Complete Part 1 by completing the one row of boxes that corresponds to your tax status.
  3. Complete Part 2 by providing your Payment Remittance Address
  4. Complete Part 3 if you are exempt from Form 1099 reporting.
  5. Complete Part 4 by signing & dating form.

Part 1 – Tax Status:(complete only one row of boxes)

Individuals:
(Fill out this row) / Individual’s Name: (first name, middle initial, last name)
______/ Individual’s Social Security Number
______- ______- ______

A sole proprietorship may have a “doing business as” trade name, but the legal name is the name of the business owner.

Sole Proprietor:
(Fill out this row) / Business Owner’s Name: (REQUIRED)
______
(First Name) (Middle Initial)
______
(Last Name) / Business Owner’s Social Security Number
______- ______- ______
or Employer ID Number
______- ______/ Business or Trade Name (OPTIONAL)
______
______
Partnership:
(Fill out this row) / Name of Partnership:
______
______/ Partnership’s Employer ID Number
______- ______/ Partnership’s Name on IRS records (see IRS mailing label)
______
______

A corporation may use an abbreviated name or its initials, but its legal name is the name on the articles of incorporation.

Corporation, exempt charity or other entity:
(Fill out this row) / Name of Corporation or Entity:
______
______/ Employer ID Number
______- ______/ Are you incorporated?
YES NO
/ D.B.A. or T.A. companies? Attach all of the business names.

Part 2 - Payment Remittance Address:

______

______

______

______

______

Part 3 – Exemption: If exempt from Form 1099 reporting, check here: AND circle your qualifying exemption reason below:

  1. Corporation
Except there is no exemption for medical and healthcare payments or payments for legal services. /
  1. Tax Exempt
Tax Exempt Charity under 501(a) (includes 501(c)(3)), or IRA /
  1. The United States or any of its agencies or instrumentalities
/
  1. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions.
/
  1. A foreign government or any of its political subdivisions.

Part 4 – 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. person (including a U.S. resident alien).

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.

Name of Person completing this form: ______

Title of Person completing this form: ______

Signature: ______Date: ______Phone: (_____) ______

Address: ______City: ______State: _____ ZIP: ______

E-Mail Address: ______