W-9 Form

updated 9/5/2023

Company Hiring You/Your Company - NOT your name/your business name

STOP!!! This form should be filled out ONLY by individuals who are being paid as an independent contractor by the above named Company. By submitting and signing this W9 form, you provide consent that you understand you will be paid as an independent contractor and that federal/state taxes will not be withheld from your pay.

For instructions on completing this form, visit: https://www.veriscpa.com/clientforms/w9-instructions/

W-9

Request for Taxpayer

Department of the Treasury

Identification Number and Certification

Internal Revenue Service

Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

Business name/disregarded entity name, if different from above

Select the appropriate federal tax classification of the person whose name is entered on line 1.

If Limited Liability Company chosen above, select the appropriate tax classification:

Note: Do not choose LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should choose the appropriate box for the tax classification of its owner.

If other chosen above, provide reason here:

Exemptions (codes apply only to certain entities, not individuals; see instructions):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

Address (number, street, and apt. or suite no.) See instructions.

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 backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social Security Number OR Employer Identification Number:

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); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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 for Part II, later.

This form is not valid unless you sign it. Type your full legal name and initials below to agree to this electronic signature submission.

Your full legal name

Initials

Date

Form W-9 (Rev. 10-2018)