Form Mo 300 1489 – Fill Out and Use This PDF

SECTIONV ND R A:DDRESSVENDOR INFORMATION – TO BE COMPLETED BY THE VENDOR (SEE SECTION A INSTRUCTIONS)

1.NAME AS SHOWN ON YOUR TAX RETURN

2.BUSINESS NAME, IF DIFFERENT FROM ABOVE

3. BUSINESS ADDRESS (NUMBER, STREET AND APT. OR SUITE NUMBER)	4. P.O. BOX NUMBER
5. CITY, STATE AND ZIP CODE	6. TELEPHONE NUMBER
7. PAYMENT ADDRESS, IF DIFFERENT FROM ABOVE

TAX IDENTIFICATION NUMBER (TIN) AND TAX FILING STATUS, AS SHOWN ON YOUR TAX RETURN

Enter your TIN in the appropriate box. The TIN provided must match IRS records for the name given on Line 1 above. For Individuals and Sole Proprietors not using a Federal Employer Identification Number (FEIN), this is your Social Security Number (SSN). For other businesses, this is your FEIN.

8. SOCIAL SECURITY NUMBER

_________ - _____ - _________

Individual

Sole Proprietor or single-owner LLC

Missouri State Employee

9. FEDERAL EMPLOYER IDENTIFICATION NUMBER

_____ - _________

Sole Proprietorship or single-owner LLC

Trust or Estate

Corporation or LLC electing Corporate status

S-Corporation

Partnership or multi-member LLC

State or Local Government

Public entity (such as public school, college or university)

Federal Government/Military

Association, Club, Religious, Charitable, Educational or other tax-exempt organization (include IRS Federal tax exemption)

SECTION B: PREVIOUS VENDOR INFORMATION (SEE SECTION B INSTRUCTIONS)

10. REASON FOR CHANGE (OWNERSHIP CHANGE, BUSINESS RESTRUCTURE, BUSINESS RELOCATION, ETC.)

11. DATE OF CHANGE

12.PREVIOUS BUSINESS NAME

13.PREVIOUS BUSINESS ADDRESS

14.PREVIOUS PAYMENT ADDRESS, IF DIFFERENT FROM BUSINESS ADDRESS

15.PREVIOUS TAX ID NUMBER

COMMENTS

SECTION C: CONTACT INFORMATION – LIST THE NAME OF SOMEONE AT YOUR BUSINESS WHO CAN ANSWER OUR QUESTIONS

CERTIFICATION FOR STATE OF MISSOURI – I certify that the above information is accurate and complete, according to the Vendor Input form instructions.

CERTIFICATION FOR INTERNAL REVENUE SERVICE (IRS)

Exempt from Backup Withholding

Under penalties of perjury, I certify that:

I. 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

II.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

III. I am a U.S. person (including a U.S. resident alien)

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 all 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 W-9 Instructions on irs.gov website for more information.) The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

MO 300-1489 (5-07)FAX COMPLETED FORMS TO (573) 526-9813 or

MAIL TO OFFICE OF ADMINISTRATION/ACCOUNTING, PO BOX 809, JEFFERSON CITY, MO 65102

VENDOR INPUT FORM INSTRUCTIONS

Fax completed form to: Office of Administration, Division of Accounting at (573) 526-9813.

SECTION A: TO BE COMPLETED BY VENDOR (ALL FIELDS REQUIRED UNLESS OTHERWISE STATED)

Lines 1 and 2: If you are an individual, enter the name shown on your income tax return. If you have changed your name without letting the Social Security Administration know, then you should enter both the name that appears on your Social Security Card and your new name.

Sole Proprietors - Enter your name, as listed on your income tax return, on Line 1. Enter your business, trade or “doing business as (DBA)” name on Line 2.

Limited Liability Company (LLC) - If you are a single-member LLC that is separate from its owner, enter the owner’s name on Line 1. Enter the LLC’s name on Line 2.

Other business types - Enter the name of your business on Line 1. This must be the name shown on the “Name” line of your federal tax return and the legal documents you filed when your business was created. If you do business under another name, that name should be listed on Line 2.

Lines 3, 4 and 5: Enter the address where we can send an IRS Form 1099, showing the dollar amount the State of Missouri paid to you, should one be required. This is usually the main mailing address for your business.

Line 6: Enter your business telephone number.

Line 7: If payments we make to you should be sent to a different address than your IRS Form 1099, enter this address on Line 7.

Lines 8 and 9: Tax Identification Number (TIN) and Tax Filing Status – Check with your tax preparer or accounting department if you are unsure how to complete this section.

If you are an individual person, a State of Missouri employee or you are the sole proprietor of a business that is not required to have an Employer Identification Number (EIN), enter your Social Security Number (SSN) on Line 8. Check the box that describes your situation.

If you file your taxes using a Federal Employer Identification Number (FEIN/EIN), enter this number on Line 9. Check the box that explains how your business files taxes with the IRS.

SECTION B: THIS SECTION IS FOR CHANGES THAT HAVE HAPPENED TO YOUR NAME, ADDRESS INFORMATION, TAX ID NUMBER OR TAX FILING STATUS.

New information should be entered in SECTION A and old information should be listed in SECTION B. Include the date that the change legally took effect and the reason for the change.

SECTION C: CONTACT INFORMATION

Give a contact name and telephone number.

Certification for State of Missouri – This section must be signed by the vendor.

Certification for Internal Revenue Service (IRS) – Sign this section if:

I.The Tax ID number you entered on the form is correct

II.You or your business is not subject to backup withholding

III. You are a US citizen or US resident alien.

If you have questions while completing this form, please call (573) 751-2971 for assistance.

MO 300-1489 (5-07)

SAM II