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School Administrative Unit #9

176A Main Street

Conway, New Hampshire 03818

www.sau9.org

 

Telephone (603) 447-8368

Special Education 603-447-8951

Fax (603) 447-8497

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ALTERNATE FORM W-9

          Payer’s Request for Taxpayer

          Identification Number and Certification

 

Pursuant to IRS Regulations, you must furnish your Taxpayer Identification Number (TIN) whether or not you are required to file tax returns.  If this number is not provided, you may be subject to a 31% withholding on each payment made to you.  To avoid this withholding and to ensure that accurate tax information is reported to the IRS, please use this form to provide the requested information and return it to the above address.

 

NAME: _________________________________________________________________________________

           As shown on IRS Tax Return

 

ADD’L or

D/B/A NAME:__________________________________________________________________________________

 

ADDRESS:_____________________________________________________________________________________

 

CITY/TOWN____________________________________  STATE _______________  ZIP CODE___________

 

TAXPAYER ID NUMBER (TIN) used on IRS Tax Return

           

            Social Security Number __ __ __ - __ __ - __ __ __ __

           

Federal Employer ID #     __ __ - __ __ __ __ __ __ __

 

PRINCIPAL BUSINESS ACTIVITY (You must select one)

 

            ____ Service Provider                                                 ____ Product/Merchandise Provider

 

List the principal type of service or product provided

 

BUSINESS DESIGNATION (You must indicate ALL that apply)

 

___Individual ___Sole Proprietorship ___Partnership ___Estate or Trust___Corporation____Governmental Entity  

 

____Personal Service Corporation____Health Care Provider____ Non-Profit (attach copy of exemption)

 

NAME & TITLE (Please print or type)  ____________________________________________________________

 

SIGNATURE:________________________________________________  DATE: _____________________

 

Telephone Number:________________________________________________________________________