Form Sub W 9 – Fill Out and Use This PDF

Form	Butler County Ohio
SUB W-9	Substitute Form W9 / Ohio Reporting Form
(Rev Oct 2004)	Request for Taxpayer Identification Number and Certification
	Landlords

Direct payment to Landlords can only be made when name is on file with the Auditor’s Office; if not complete this form for direct payment may be made. In order to maintain Butler County’s supplier records in compliance with the Internal Revenue Service regulation1.0641-1 and Ohio Revised Code section

3121.89-3121.8911, please complete and return to your Veteran Benefits Coordinator when returning the Landlord Statement; suppliers may fax form to : 513-887-3519 – Attention: Anna, if more comfortable doing so. (Allow 7-10 days for processing.)

Butler County Veterans Service Commission

315 High Street – 1st Floor	1021 Central Avenue
Hamilton, Ohio 45011	Middletown, Ohio 45044
Phone: (513) 887-3600	Phone: (513) 425-8688
Fax: (513) 887-3519	Fax: (513) 425-8739

Email Address: vsc@butlercountyohio.org

To properly complete the form, the following information must be provided:

1.Part I, line 1, enter the business owner’s name (if applicable), part 1, line 2, business name (if applicable), organization type, and address.

2.Part II, you must provide either a Taxpayer Identification Number (TIN) or Social Security Number (SSN)

3.Part III, you must check “Yes” or “No” to the question about providing goods or services as the sole owner of your business. If you check the “Yes” box to indicate that you are the sole owner, you must provide the first date of providing goods or services for Butler County, birth date, and description of the type of good or service you will provide the county. Additionally, you must provide the sole owner’s SSN in Part II, even if a

TIN has already been provided.

4.Part IV, sign the form and enter today’s date.

For definitions of Part I and II of this form, please refer to IRS Form W-9.

Part I Business Ownership and Address Information

Individual’s / Business owner’s name (if sole owner of your business, sole owner of an LLC or sole owner of a corporation

Business name, if different from above

Check appropriate box for organization type

Individual /

________

Exempt from backup

Sole Proprietor

Corporation

Partnership

Other

withholding

Address Line 1 (number, street, and apt. or suite no.)

Requestor’s name and address

Address Line 2

Auditor of Butler County

130 High Street, Fiscal Services Dept.

Hamilton, OH 45011

City, state, and ZIP code

Part II

Taxpayer Identification Number (TIN) and Social Security Number (SSN)

For suppliers that have a TIN, this must be entered.

Taxpayer Identification Number (TIN)

For individuals, sole proprietors, and corporations owned by an individual, you must

-

generally enter the name shown on your social security card. However, if you have changed

your last name, for instance due to marriage without informing the Social Security

And / or

Administration of the name change, enter your first name, the last name shown on your

Social Security Number (SSN)

social security card, and your new last name. You may enter your business or DBA name on

-

_

the Business name line.

Part III Additional Information Required by the State of Ohio for Independent Contractors

Are you the sole owner of your business that provides goods or services for compensation under a written or verbal contract with Butler County?

Yes Or

No

Describe the type of good or service you will be providing to the county.

Part IV Certification

Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).

2.I am not subject to backup withholding because, (a) I am exempt from backup withholding, or (b) I have not been notified by the 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.

3.I am a US person (including a US resident alien).

Certification Instructions: You must cross out exempt from backup withholding above if you have been notified by the IRS that your are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

	Signature of	Date _____________________________
	U.S. person_______________________________________________________________________