Doa 6448 Form – Fill Out and Use This PDF

Printed Name

Printed Title

Telephone Number

Signature

Date (MM/DD/CCYY)

Agency Number

Contact

Phone Number

Change

Name

Address

Other (explain)

Legal Name As entered with IRS

Individuals: Enter Last Name, First Name, M.I.

Sole Proprietorships: Enter Last Name, First Name, M.I.

LLC Single Owner: Enter owner's Last Name, First Name, M.I.

All Others: Enter Legal Name of Business

Trade Name

Individuals: Leave Blank

Sole Proprietorships: Enter Business Name

LLC Single Owner: Enter LLC Business Name

All Others: Complete only if doing business as a D/B/A

Remit Address

Address where payment should be mailed.

Order Address

Address where order should be mailed. Complete only if different from remit address.

1099 Address

Address where 1099 should be mailed. Complete only if different from remit address.

Entity Designation

Check ONE box which describes the type of business entity.

Taxpayer Identification Number (TIN)

LIST ONLY ONE: Social Security Number OR Employer Identification Number OR Individual Taxpayer Identification Number. See “What Name and Number to Give the Requester” at right.

If you do not have a TIN, apply for one immediately. Individuals use federal form SS-05 which can be obtained from the Social Security Administration. Businesses and all other entities use federal form SS-04 which can be obtained from the Internal Revenue Service.

Certification

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.

Privacy Act Notice

Section 6109 requires you to furnish 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, or contributions you made to an IRA. The IRS uses the numbers for

identification purposes and to help verify the accuracy of your tax return. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not furnish a TIN to a payer. Certain penalties may also apply.

What Name and Number to Give the Requester

For this type of account:		Give name and SSN of:
1.	Individual	The individual
2.	Two or more individuals (joint	The actual owner of the account
	account)	or, if combined funds, the first
		individual on the account 1
3.	Custodian account of a minor	The minor 2
	(Uniform Gift to Minors Act)
4. a. The usual revocable savings		The grantor-trustee 1
	trust (grantor is also trustee)
	b. So-called trust account that	The actual owner 1
	is not a legal or valid trust
	under state law
5.	Sole proprietorship or Single-	The owner	3
	Owner LLC
For this type of account:		Give name and EIN of:
6.	Sole Proprietorship or Single-	The owner 3
	Owner LLC
7.	A valid trust, estate, or pension	Legal entity 4
	trust
8.	Corporation or LLC electing	The corporation
	corporate status on Form
	8832
9.	Association, club, religious,	The organization
	charitable, educational, or
	other tax-exempt organization
10. Partnership or multi-member		The partnership
	LLC
11. A broker or registered		The broker or nominee
	nominee
12. Account with the Department		The public entity
	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

1List 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 D/B/A 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.