Substitute W-9 & Supplier Information Form: Complete Guide form

School: Southern New Hampshire University - Course: BUSINESS A 21 - Subject: Accounting

Substitute W-9 & Supplier Information Form SUPPLIER INFORMATION 1 NAME(as registered with the IRS) TRADE NAME/DBA PRIMARY ADDRESS(number, street, and apt or suite no)REMITTANCE ADDRESS(if different from primary) CITY, STATE, and ZIP+4 CODECITY, STATE, and ZIP+4 CODE PHONEFAXEMAIL TAX CLASSIFICATIONINDIVIDUAL/SOLE PROPRIETOR, OR SINGLE-MEMBER LLCC CORPORATIONS CORPORATIONPARTNERSHIPTRUST/ESTATE LIMITED LIABILITY COMPANY - Enter tax classification (C=C Corp, S=S Corp, P=Partnership) _____ OTHER __________________________________ EXEMPTIONS EXEMPT PAYEE CODE (if any) ________ EXEMPTION FROM FATCA REPORTING CODE (if any) _______________________ TAXPAYER IDENTIFICATION NUMBER (TIN)Will you be selling goods and/or services to UCSF? NO YES* *If YES, Section 2 Payment Options is REQUIRED DUN & BRADSTREET NUMBERUNSPSC CODE(if applicable) PAYMENT OPTIONS 2 Select ONE:Immediate with Virtual Card/Payment Plus payment(PREFERRED) 2%10,N30 with ACH payment N30 with ACH payment N60 with check payment PURCHASE ORDER EMAIL PURCHASE ORDER FAX BUSINESS DIVERSITY 3FEDERAL CERTIFICATIONS(self-certify on the federalSystem for Award Managementwebsite)ANC1 (Alaska Native Corp not certified as SDBSBE (Small Business Enterprise) with SBA)SDB (Small Disadvantaged Business) ANC2 (Alaska Native Corp not a small business)SDVOSB (Service-Disabled Veteran-Owned HBCU/MI (Historically Black College or MinoritySmall Business) Institution)VOSB (Veteran-Owned Small Business) Hub Zone (Historically Under-Utilized SmallWBE (Women Business Enterprise) Business)WOSB (Women-Owned Small Business) MBE (Minority Business Enterprise)STATE OF CALIFORNIA CERTIFICATIONS (self-certify on the State of CA website) DBE(Disadvantaged Business Enterprise) DVBE(Disabled Veteran Business Enterprise) SBE(Small Business Enterprise) WBE(Women Business Enterprise) ABILITY ONE PROGRAM ABILITY ONE REQUESTER'S INFORMATION 4 UCSF CONTACT NAMEUCSF CONTACT EMAIL CERTIFICATION 5 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); 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. citizen or other U.S. person (defined in the IRS Form W-9 instructions); and 4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return. The Internal Revenue Service does not require your consent to any provision on this document other than the certifications required to avoid backup withholding. SIGNATUREDATE PRINT NAMETITLE SUBMIT COMPLETED FORM TO[email protected] SOCIAL SECURITY NUMBER¦¦ EMPLOYER IDENTIFICATION NUMBER ¦OR

2Version 20.6Guide for the Substitute W9 and Supplier Information Form 1.SUPPLIER INFORMATIONprovide information about your company. 2.PAYMENT OPTIONS PAYMENT METHODS: Virtual Card/Payment Plus Payment Plus is UCSF s preferred electronic method for issuing payments to suppliers. Payment is made via a onetime use virtual credit card number issued by U.S. Bank. Merchant interchange fees apply. For more information visit. ACH payment by electronic funds transfer. A business bank account is required. Paper check Least preferred method of payment. Our goal is to minimize paper check payments made to suppliers. PAYMENT TERMS: Immediate payment is generated 1 business day after the invoice is processed 2%10,N30 a 2% discount is taken if the invoice is paid within 10 days of the invoice received date; otherwise, invoice is paid in full 30 days from invoice date N30 payment is generated 30 days from invoice date N60 payment is generated 60 days from invoice date PURCHASE ORDERSprovide a fax number and/or email address for Purchase Order delivery. 3.BUSINESS DIVERSITYselect all for which your business has selfcertified as defined in the Ability One Program, the System for Award Management, or on the State of California website. Refer to the links for each program and the State of California for selfcertification. 4.REQUESTER S INFORMATIONprovide your UCSF contact s name and email address. 5.CERTIFICATIONsign and date the Certification. Substitute W9 Form Disclosures PRIVACY ACT NOTICE: Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.