Vendor Information Form – Fill Out and Use This PDF

Instructions for Completing the Vendor Information Form

U of I Department:

Complete the "UI Department Requesting Information" section prior to sending form to the vendor. Forms without this section completed will not be processed.

Vendor:

Step 1 -- Complete the form

You may use this form in two ways:

• Enter your information (Start with Section 1 - Tax Information). Print, sign and submit the form to the address below.

OR

•Print the form, complete with your information(Start with Section 1 -Tax Information), sign and submit to the appropriate address below.

Step 2 -- Submit the Form

To help ensure the security of your tax identification information, return this form directly to:

Mail: Vendor Maintenance Section

Illini Plaza Bldg, Suite 210, MC-660

1817 S. Neil Street

Champaign, IL 61820

Fax: (217) 239-6850

You do not need to mail a hardcopy.

Documents must be signed and dated.

Revised 6/2014

OBFS - University Payables

Permanent Residence/Corporate Office Address

Address
City				State				Zip Code
Phone		Fax				E-mail

Payment Address (if different from above)

Address

City				State			Zip Code
Phone		Fax				E-mail

Purchase Order Address (if different from above)

Address

City				State			Zip Code
Phone		Fax				E-mail

Individuals: Please check the appropriate classification.

U.S. Citizen	US Permanent Resident	Resident Alien for Tax Purposes	Non-Resident Alien	W-8BEN
	Resident Aliens must provide a copy of		Non-Resident Aliens are not
	their Permanent Resident Card when		required to certify in Step 3, but
	submitting this form.		must attach W-8BEN.

Businesses: Please check the appropriate classification.

U.S. Company

Foreign Vendor with US Presence

W-8ECI

Foreign Vendor

W-8BEN-E

W-8EXP

Types of Goods and Services Provided

Goods	Services		Attorney	Royalties	Medical
Other	Please Describe:

Step 2 -- Type of Operation (optional, check all that apply)

Diverse Business

African American (CA)	Asian American (CM)	Female (CW)
Hispanic American (CH)	Alaskan Native/Native American (CN)	Veteran (CV)
Disabled (CD)

Small Business

Certifying Organization

DCMS (Department of Central Management Services) Business Enterprise Program (C2)

CMBDC (Chicago Minority Business Development Council) (C3)*

IDOT (Illinois Department of Transportation) (C4)*

WBDC (Women's Business Development Center) (C5)*

Other (Please specify):

* Please provide letter of certification from certifying agency when submitting this form.

Step 3 -- Certification and Signature

Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number and

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 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

3.I am a U. S. person (including a U. S. resident alien].

4.I or the organization I represent will comply with the provisions of the Health Insurance Portability and Accountability

Act of 1996 (HIPAA), and the regulations promulgated there under, to the extent applicable in each transaction. 5. Neither the organization I represent nor any of its employees or subcontractors who may provide services pursuant

to any Contract with the University of Illinois is currently Subject of an investigation or proceeding to exclude it as a provider under Medicare or Medicaid or under any other federal or state health care program or under any third party insurance program, nor is it currently excluded or debarred from submitting claims to Medicare or Medicaid or to any other federal or state health care program or to any third party insurer. My organization represents and warrants it has checked the U. S. General Service Administration's (GSA) Excluded Party Listing System (EPLS), which lists parties excluded from Federal procurement and non-procurement programs. The EPLS website includes GSA/EPLS, the U. S. Department of Health and Human Services (HHS) Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE), and the U.S. Department of Treasury's (Treasury) Specially Designated Nationals (SDN) list. My organization also represents and warrants it has checked the Illinois Department of Public Aid (IDPA) OIG Provider Sanctions list of individuals and entities excluded from state procurement with respect to my organization's employees and agents. See the following websites: System for Award Management and State of Illinois Healthcare and Family Services Office of Inspector General. University will terminate any contract without penalty to University if my organization becomes excluded during the life of any contract.

6.I certify that the information contained herein is correct. I understand that misrepresentation may be cause for removal from the qualified vendor list and any other penalties allowed by law.

7.If any of the vendor information on this form changes the vendor must complete a new form and check updated vendor information. The form must then be resubmitted to the address indicated at the bottom of page four of this form.

Vendor Signature (This form is not considered valid unless signed and dated)

Signature of U.S. Person:					Date:
Printed Name:					Phone Number:
E-mail (optional):

Revised 6/2014

OBFS - University Payables

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Vendor Information Form Additional Instructions

The University is required by Federal Law to report such payments along with SSN/FEIN to Federal and State Agencies on forms required by law. The University will not disclose a recipient's SSN or FEIN without the consent of the recipient to anyone outside the University except as mandated by law. Your failure to provide a correct name and Taxpayer Identification Number may subject your payments to 28% federal income tax withholding. If you do not provide us with information, you may be subject to a $50 penalty imposed by IRS under section 6723. If you make a false settlement with no reasonable basis that results in no backup withholding, you are subject to a $500 civil penalty. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

W-9 Taxpayer Information

*If you use a SSN, the IRS requires that you include the name of the individual whose SSN has been entered.

*Non-profit organizations and government agencies should list your Taxpayer Identification Number as recorded with the

IRS.

*Sole Proprietors: Must enter your individual name (as shown on your Social Security card) on the Name of Individual or Business Name line as well as your business or “doing business as” name on the Business Name line. For the Taxpayer Identification Number, enter either your Social Security Number or the Federal Employer Identification Number of the business.

*Business Name: Enter the name of the entity as it is listed with the IRS on the Form SS-4, Application for Employer Identification Number. This name should be consistent with the name used on your tax returns.

*Foreign companies should complete the appropriate W8 and submit along with the Vendor Information Form to the Vendor Maintenance Department.

*Foreign individuals should complete the W8BEN and return it directly to the University Department Contact listed at the

top of this form.

Resident Alien

Resident Aliens must provide a copy of their Permanent Resident Card when submitting this form.

Non-Resident Alien

Non-Resident Aliens are not required to certify in Part IV, but must attach W-8BEN.

Foreign Vendors with US Presence

Foreign Vendors with US Presence are not required to certify in Part IV, but must attach W-8ECI.

Foreign Vendors

Foreign Vendors are not required to certify in Part IV, but must attach W-8BEN or W-8EXP as appropriate.

Diverse Business

You are considered a diverse business if you meet the following criteria:

-At least 51 percent owned and controlled by persons who are minority, women or designated as disabled.

-Must be a United States Citizen or Resident Alien

-Average annual gross sales over the last three tax years must be under $31.4 million

Small Business

You are considered a small business if you meet the following criteria:

·An Illinois business

·Annual gross sales:

-Retail/Service less than $6 Million

-Wholesale less than $10 million

-Construction less than $10 Million

-Manufacturing less than $10

Million and less than 250 employees

Revised 6/2014

OBFS - University Payables

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