Fillable Printable Request for Taxpayer Identification Number and Certification
Fillable Printable Request for Taxpayer Identification Number and Certification
Request for Taxpayer Identification Number and Certification
Form
W-9
(Massachusetts Substitute W-9 Form)
Rev. April 2009
Request for Taxpayer
Identification Number and Certification
Completed form should be
given to the requesting
department or the department
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
Phone # ( ) Fax # ( ) Email address:
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social
security number (SSN). However, for a resident alien, sole proprietor, or
disregarded entity, see the Part I instruction on
page 2. 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 2.
Note: If the account is in more than one name, see the chart on page 2 for
guidelines on whose number to enter.
Vendors:
Dunn and Bradstreet Universal Numbering System (DUNS))
Social security number
- -
OR
Employer identification number
-
DUNS
Part II Certification
Please print or type
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 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.
Sign
Here
Authorized Signature ► Date ►
Purpose of Form
A person who is required to file an information
return with the IRS must get your correct
taxpayer identification number (TIN) to report, for
example, income paid to you, real estate
transactions, mortgage interest you paid,
acquisition or debt, or contributions you made to
an IRA.
Use Form W-9 only if you are a U.S. person
(including a resident alien), to give your correct
TIN to the person requesting it (the requester)
and , when applicable, to:
1.
Certify the TIN you are giving is correct (or
you are waiting for a number to be issued).
2.
Certify you are not subject to backup
withholding
If you are a foreign person, use the
appropriate Form W-8. See Pub 515,
Withholding of Tax on Nonresident Aliens and
Foreign Corporations.
What is backup withholding? Persons making
certain payments to you must withhold a
designated percentage, currently 28% and pay to
the IRS of such payments under certain
conditions. This is called “backup withholding.”
Payments that may be subject to backup
withholding include interest, dividends, broker and
barter exchange transactions, rents, royalties,
nonemployee pay, and certain payments from
fishing boat operators. Real estate transactions
are not subject to backup withholding.
If you give the requester your correct TIN, make
the proper certifications, and report all your
taxable interest and dividends on your tax return,
payments you receive will not be subject to
backup withholding. Payments you receive will
be subject to backup withholding if:
1.
You do not furnish your TIN to the
requester, or
2.
You do not certify your TIN when required
(see the Part II instructions on page 2 for
details), or
3.
The IRS tells the requester that you furnished
an incorrect TIN, or
4.
The IRS tells you that you are subject to
backup withholding because you did not
report all your interest and dividends only), or
5. You do not certify to the requester that you are
not subject to backup withholding under 4 above
(for reportable interest and dividend accounts
opened after 1983 only).
Certain payees and payments are exempt from
backup withholding. See the Part II instructions
on page 2.
Penalties
Failure to furnish TIN. If you fail to furnish your
correct TIN to a requester, you are subject to a
penalty of $50 for each such failure unless your
failure is due to reasonable cause and not to
willful neglect.
Civil penalty for false information with respect
to withholding. If you make a false statement
with no reasonable basis that results in no backup
withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information.
Willfully falsifying certifications or affirmations
may subject you to criminal penalties including
fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses
TINs in violation of Federal law, the requester may
be subject to civil and criminal penalties.
Form
MA- W-9 (Rev. April 2009)
What Name and Number to
Give the Requester
For this type of account: Give name and SSN of:
1.
Individual
2.
Two or more
individuals (joint
account)
3.
Custodian account of
a minor (Uniform Gift
to Minors Act)
4.
a. The usual
revocable savings
trust (grantor is
also trustee)
b. So-called trust
account that is not
a legal or valid
trust under state
law
5.
Sole proprietorship
The individual
The actual owner of the
account or, if combined
funds, the first
individual on the
account
1
The minor
2
The grantor-trustee
1
The actual owner
1
The owner
3
For this type of account: Give name and EIN of:
6.
Sole proprietorship
7.
A valid trust, estate, or
pension trust
8.
Corporate
9.
Association, club,
religious, charitable,
educational, or other
tax-exempt organization
10.
Partnership
11.
A broker or registered
nominee
12.
Account with the
Department of
Agriculture in the name
of a public entity (such
as a state or local
government, school
district, or prison) that
receives agricultural
program payments
The owner
3
Legal entity
4
The corporation
The organization
The partnership
The broker or nominee
The public entity
Specific Instructions
Name. If you are an individual, you must
generally enter the name shown on your social
security card. However, if you have changed
your last name, for instance, due to marriage
without informing the Social Security
Administration of the name change, enter your
first name, the last name shown on your social
security card, and your new last name.
If the account is in joint names, list first and
then circle the name of the person or entity
whose number you enter in Part I of the form.
Sole proprietor. Enter your individual name
as shown on your social security card on the
“Name” line. You may enter your business,
trade, or “doing business as (DBA)” name on
the “Business name” line.
Limited liability company (LLC). If you are a
single-member LLC (including a foreign LLC
with a domestic owner) that is disregarded as
an entity separate from its owner under
Treasury regulations section 301.7701-3, enter
the owner’s name on the “Name” line. Enter
the LLC’s name on the “Business name” line.
Caution: A disregarded domestic entity that
has a foreign owner must use the appropriate
Form W-8.
Other entities. Enter your business name as
shown on required Federal tax documents on
the “Name” line. This name should match the
name shown on the charter or other legal
document creating the entity. You may enter
any business, trade, or DBA name on the
“Business name” line.
Part I - Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate
box.
If you are a resident alien and you do not
have and are not eligible to get an SSN, your
TIN is your IRS 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 below.
If you are a sole proprietor and you have an
EIN, you may enter either your SSN or EIN.
However, the IRS prefers that you use your
SSN.
If you are an LLC that is disregarded as an
entity separate from its owner (see Limited
liability company (LLC) above), and are
owned by an individual, enter your SSN (or
“pre-LLC” EIN, if desired). If the owner of a
disregarded LLC is a corporation, partnership,
etc., enter the owner’s EIN.
Note: See the chart on this page for further
clarification of name and TIN combinations.
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 Card, from your local Social Security
Administration office. Get Form W-7, Application
for IRS Individual Taxpayer Identification Number,
to apply for an ITIN or Form SS-4, Application for
Employer Identification Number, to apply for an
EIN. You can get Forms W-7 and SS-4 from the
IRS by calling 1-800-TAX-FORM (1-800-829-
3676) or from the IRS’s Internet Web Site
www.irs.gov.
If you do not have a TIN, write “Applied For” in
the space for the TIN, sign and date the form, and
give it to the requester. For interest and dividend
payments, and certain 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 are subject to backup
withholding on payments.
The 60-day rule does not apply to other types of
payments. You will be subject to backup
withholding on all such payments until you
provide your TIN to the requester.
Note: Writing “Applied For” means that you have
already applied for a TIN or that you intend to
apply for one soon.
Part II - Certification
To establish to the paying agent that your TIN is
correct or you are a U.S. person, or resident
alien, sign Form W-9.
For a joint account, only the person whole TIN is
shown in Part I should sign (when required).
Real estate transactions. You must sign the
certification. You may cross out item 2 of the
certification.
Dunn and Bradstreet Universal Numbering
System (DUNS) number requirement –
The United States Office of Management and Budget
(OMB) requires all vendors that receive federal grant
funds have their DUNS number recorded with and
subsequently reported to the granting agency. If a
contractor has multiple DUNS numbers the
contractor should provide the primary number listed
with the Federal government’s Central Contractor
Registration (CCR) at /www.ccr.gov
. Any entity that
does not have a DUNS number can apply for one on-
line at http://www.dnb.com/us/
under the DNB D-U-N Number Tab.
Privacy Act Notice
Section 6109 of the Internal Revenue Code
requires you to give 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 MSA. 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, and the District of
Columbia to carry out their tax laws
You must provide your TIN whether or not you
are required to file a tax return. Payers must
generally withhold a designated percentage,
currently 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.
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, but you may
also enter your business or “DBA” name. You may
use either your SSN or EIN (if you have one).
4
.
List first and circle the name of the legal 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.)
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.
If you have questions on completing this form,
please contact the Office of the State Comptroller.
(617) 973-2468.
Upon completion of this form, please
send it to the Commonwealth of
Massachusetts Department you are
doing business with.
Form
MA- W-9 (Rev. April 2009)
Page 2
