Form Sr 97 36 – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

10/97

ALTERNATE W-9 FORM-CIS

PAYER’S REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

PLEASE USE THIS FORM TO PROVIDE THE REQUESTED INFORMATION

Please furnish us with your Taxpayer Identification Number (TIN) whether or not you are required to file tax returns. Complete the below information and return this form as soon as possible. NOTE: Checks will be made payable to and mailed to the below name and address. The name must match the TIN given.

Name:

Address:

City/State/Zip:

TAXPAYER IDENTIFICATION NUMBER INFORMATION

Please indicate what the number below is - CHECK ONLY ONE:

EMPLOYER IDENTIFICATION NUMBER ORSOCIAL SECURITY NUMBER

NUMBER USED ON IRS TAX RETURN: ____ ____ ____ ____ ____ ____ ____ ____ ____

(This number must be the one assigned to the name given above)

DESIGNATION - Select ONE that best describes your business. For more information see the letter enclosed with this form.

Corporation (N)

Government (Federal/State/Local) (N)

Non-Profit (attach copy of exemption) (N)

Other - Please indicate what you are providing: (check one) ___Services (Y) ___Goods (N) List the principal type of service, product or other you provide:

Under penalty of perjury, I declare that the information provided is true, correct and complete, to the best of my knowledge and belief.

Name & Title (PRINT OR TYPE)
Signature					DATE:
Telephone #:					EXT.:
							SR 97-36

INSTRUCTIONS FOR COMPLETING ALTERNATE W-9 FORM

Please complete ALL sections of the form. If any section is left blank, the form will be returned and direct payment to you may be delayed.

Please complete the name and address portion of the form as you wish to have payments made.

NAME

This is the name to whom checks will be made payable. It must be the name that matches the taxpayer identification number indicated on the form.

ADDRESS and CITY/STATE/ZIP

This is the address to which checks will be mailed.

SOCIAL SECURITY NUMBER or EMPLOYER IDENTIFICATION NUMBER

This is used to indicate what type of number is being used as the taxpayer identification number. Check one box only to indicate what type the taxpayer identification number is.

NUMBER USED ON IRS TAX RETURN

This number should be that which is assigned to the name indicated on the form. Be sure to fill in all 9 digits.

DESIGNATION

Please select the designation which best describes your business. The following is a brief description of each:

Corporation:	You are incorporated
Government: You are a federal/state/local government agency.
Non-Profit:	You are a non-profit agency. You will need to supply a copy of your tax
	exemption.
Other:	You do not fit any of the above three designations. Please indicate
	whether you provide services or goods.

TYPE OF SERVICE

List the type of service or goods that you provide. The following is a brief description of each.

Services:	Child Care, tutoring, tuition, fees, counseling, case management,
	transportation, etc.
Goods:	Books, supplies, uniforms, tools of the trade, etc.

MISCELLANEOUS

Please complete the form by printing or typing in your name and title (if applicable), signature, date, and telephone number where you may be reached during the week day. This information should be accurate and readable in the event that we need to contact you for clarification or additional information. Remember, if you need any assistance in completing the form or have any questions about our program, call the number on the attached letter or the local New Hampshire Employment Program Team. If you have questions about the tax-related information on this form, or questions about receiving IRS Form 1099, you may call the Department’s Office of Finance at (603) 271-4098.