HomeMy WebLinkAboutRankin, Thomas CIQ 09.21.26)------------------·-----l
DENTON
City of Denton Purchasing
901-B Texas St. Denton, TX 76209
Phone: (940) 349-7100 Fax. (940) 349-7302 www.dentonpurchasing.com
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.
Name as shown on your income tax return: :=lio�s L�l:�
Tax ID/Social Security#:
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 oth .S. person-for fededral tax purposes as defined at the bottom of this paoe*.4. I unsderstand that I must disclose a on I of interest in accordance with Section 176.006 (a-1) of the Local Government"Code. ----,r �, \ � () Authorized Signatur----�-..J-�J--'---'-..JI.--X-::>1.--Printed Name:�--a-. S /.J, N....,k,;r.,_
Mailing Address: Company Name: _ ___.lY_._0 .... A_._ ____ -.--__ _ R.c-k l'>
fA,..,J .. tc'.51: 0 r :v-e,
75"'70 I
Check appropriate box for federal tax classification (required):
� / Individual/ U Sole
D
Proprietor
Exempt Payee
Business Type
Type of Organization:
D Corporation
Must designate C or S
D C
D s
Real Estate D RentaVl.ease (A 1)
� Services Only (A-
7)
ConsultanVProf □Fees (A-7)
D Minority Owned
D Partnership
Equipment D RentaVl.ease (A-9)
Merchandise-D Goods Only (A-7)
Proceeds from Real Estate □Purchases (S)
D Female Owned
D
D
Limited Liability Corporation
Royalties (A-2)
Merchandise &
Services (A• 7)
D Non Profit
D
D Medical/Health Care (A-6)
□Legal Firm/Attorney (A-C)
0 Historically Underutilized Business
*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).
COD . Page 1 9/23/2011
Vendor Information Not Required for W-9 Form
Remit Address (if different from above)
Company Name: _____________ _
Contact Name: _____________ _
Address: _____________ _
Email: --------------
Phone Number: --------------
Fax Number: --------------
ACH Information-Voluntary
ASA Routing#: _____________ _
Contact Name: ______________ _
Bank Account# ______________ _
Bank Name: ______________ _
ACH Email: ---------------
ACH Email: ____________ _
Phone Number: ______________ _
Fax Number: ______________ _
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
Vendor Signature ___ ,__,.1--......,'---"---
Print Name/Title __ \ __ , �._..--4---='--'--'--.:--.....::...
Date 9 /z., \ /1-0 ub•I
..::L::_is::.t:..:P:....:.:ro:.:d:.:u:.:c:.:t::.s..::a:.:.n:.::d::.:lo::::r�S=erv:.;__::ic::::e:.:s::...:.:.ln:..:t.::.e:.:re:.:s:..:t.::.ed::...::in:.:...::B:.:i::.d::.d::.in:;g1..:.:_---1�.!I....L..l�....!..���l)�"""-l>::::::.. __ ...l,__�.__-=::..L=-"'--'-g.:.��1...:J:::..._�.....:.....,o1:::....,._e,::..."---�
For Internal Use Only
0 NewVendor
D Vendor Change
0 Refund
Requesting Department: ______________ _
Vendor Number
Date:
Department Representative (Printed Name) _________________________ _
Purchasing Signature: Date:
coo Page 2 9/23/2011