Stubbs, Jennifer Sub W9 4.25.24 Tax ID/Social Security #:
Individual/
Sole
Proprietor
Partnership
Limited
Liability
Corporation
Other
Please specify:
Exempt
Payee
Business Type :Equipment
Rental/Lease (A-9)Royalties (A-2)
Medical/Health Care (A-6)
Merchandise-
Goods Only (A-7)
Merchandise &
Services (A-7)Legal Firm/Attorney (A-C)
Proceeds from
Real Estate
Purchases (S)
Type of Organization:Female Owned Non Profit Historically Underutilized
Business
City of Denton Purchasing
901-B Texas St. Denton, TX 76209
Phone: (940) 349-7100 Fax: (940) 349-7302
www.dentonpurchasing.com
Authorized Signature:____________________________ Printed Name:_______________________________________
Mailing Address:
Consultant/Prof
Fees (A-7)
Company Name:
Real Estate
Rental/Lease (A1)
Check appropriate box for federal tax classification (required):
Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxtaxpayer 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 witholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding
as a result of 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 US citizen or other U.S. person-for fededral tax purposes as defined at the bottom of this page*.
*Definition of a U.S. Person-For Federal Tax purposes, you are considered a U.S. person if you are: (a) an individual who is a U.S. citizen or
U.S. resident (b) a partnership, corporation, company, or association created or organized in the United States or under the laws of the United
States (c) an estate (other than a foreign estate), or (d) a domestic trust (as defined in Regulations Section 301.7701-7).
C
Corporation
Minority
Owned
Name as shown on your income tax return:
Substitute W-9 Form
The IRS requires all vendors to complete a W-9 Form. The information on this form must be filled out, signed and submitted by a
vendor representative. All information must be completed before a purchase order or payment will be issued.
Services Only (A-
7)
Contact Name:
Address: Phone Number:
Fax Number:
S
Must designate C or S
Email:
Website:
COD Page 1 9/23/2011
Remit Address (if different from above)
Email:
List Products and/or Services Interested in Bidding:
For Internal Use Only
Requesting Department: Date:
Purchasing Signature: Date:
ACH Information-Voluntary
I (we) authorize the City of Denton to deposit
payments into the checking account listed. The
authority remains in effect until the City of Denton
has received written notification from me of
termination in time to allow reasonable opportunity
to act on it, or until the City of Denton has sent me
written notice of termination of the agreement.
Bank Name :
ABA Routing#:
Contact Name :
Bank Account#
Vendor Number
Company Name:
Contact Name:
Address:
ACH Email :
Phone Number: Phone Number:
Fax Number: Fax Number:
Vendor Change
Refund
New Vendor
Vendor Signature __________________________
Print Name/Title ____________________________
Date _____________________________________
Department Representative (Printed Name) ________________________________________________________
ACH Email :
Vendor Information Not Required for W-9 Form
COD Page 2 9/23/2011