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Print Form Completed form should be Request for Taxpayer Form W-9 given to the requesting (Massachusetts Substitute W-9 Form) Identification Number and Certification department or the department Rev. April 2009 you are currently doing business with. Name ( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2) Business name, if different from above. (See Specific Instruction on page 2) Check the appropriate box: □ Individual/Sole proprietor □ Corporation □ Partnership □ Other ►----------------------------------------------- Legal Address: number, street, and apt. or suite no. Remittance Address: if different from legal address number, street, and apt. or suite no. City,state and ZIP code City, state and ZIP code Please print or type Phone # ( ) Fax # ( ) Email address: Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social Social security number security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part Iinstruction on -- page 2. For other entities, it is your employer identification number (EIN). If OR you do not have a number, see How to get a TIN on page 2. Note: If the account is in more than one name, see the chart on page 2 for Employer identification number guidelines on whose number to enter. - Vendors: DUNS Dunn and Bradstreet Universal Numbering System (DUNS)) 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 Services (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 an U.S. person (including an U.S. resident alien). 4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No____ Yes _____ If yes, in compliance with the State Ethics Commission requirements. Certification instructions: You must cross out item 2above 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 2does not apply. Sign Here Authorized Signature ► Date ► Purpose of Form conditions. This is called “backup withholding.” 5. You do not certify to the requester that you are A person who is required to file an information Payments that may be subject to backup not subject to backup withholding under 4 above return with the IRS must get your correct withholding include interest, dividends, broker and (for reportable interest and dividend accounts taxpayer identification number (TIN) to report, for barter exchange transactions, rents, royalties, opened after 1983 only). example, income paid to you, real estate nonemployee pay, and certain payments from transactions, mortgage interest you paid, fishing boat operators. Real estate transactions Certain payees and payments are exempt from acquisition or debt, or contributions you made to are not subject to backup withholding. backup withholding. See the Part II instructions an IRA. on page 2. If you give the requester your correct TIN, make Use Form W-9 only if you are a U.S. person the proper certifications, and report all your Penalties (including a resident alien), to give your correct taxable interest and dividends on your tax return, TIN to the person requesting it (the requester) payments you receive will not be subject to Failure to furnish TIN. If you fail to furnish your and , when applicable, to: backup withholding. Payments you receive will correct TIN to a requester, you are subject to a be subject to backup withholding if: penalty of $50 for each such failure unless your 1. Certify the TIN you are giving is correct (or failure is due to reasonable cause and not to you are waiting for a number to be issued). 1. You do not furnish your TIN to the willful neglect. requester, or 2. Certify you are not subject to backup Civil penalty for false information with respect withholding 2. You do not certify your TIN when required to withholding. If you make a false statement (see the Part II instructions on page 2 for with no reasonable basis that results in no backup If you are a foreign person, use the details), or withholding, you are subject to a $500 penalty. appropriate Form W-8. See Pub 515, Withholding of Tax on Nonresident Aliens and 3. The IRS tells the requester that you furnished Criminal penalty for falsifying information. Foreign Corporations. an incorrect TIN, or Willfully falsifying certifications or affirmations may subject you to criminal penalties including What is backup withholding? Persons making 4. The IRS tells you that you are subject to fines and/or imprisonment. certain payments to you must withhold a backup withholding because you did not designated percentage, currently 28% and pay to report all your interest and dividends only), or Misuse of TINs. If the requester discloses or uses the IRS of such payments under certain TINs in violation of Federal law, the requester may be subject to civil and criminal penalties. Form MA- W-9 (Rev. April 2009)
