SUBSTITUTE FORM W-9 and Vendor Information Form

HC 573 (06/2015)
Hennepin County General Accounting
A-12 Government Center MC 128
300 South 6th Street
Minneapolis, MN 55487-0128
SUBSTITUTE
FORM W-9
and Vendor Information Form
Email: [email protected]
IMPORTANT TAX INFORMATION - PLEASE READ THIS NOTICE CAREFULLY
This form was developed to comply with Internal Revenue Service (IRS) regulations and Minnesota statute and to assist Hennepin County in
paying providers and vendors for their goods and services. You, as a payee, are required by law to provide us, as payer, your correct Taxpayer
Identification Number (TIN). This information will only be shared with the IRS. The Minnesota Government Data Practices Act classifies the Social
Security Number as private. Unless otherwise provided by law, the home address is also private. Direct questions to 612-348-2976.
Failure to respond to this request can result in IRS-mandated withholding on future payments as well as other penalties.
If you are an existing Hennepin County vendor and wish to update your information, check this box:
Update information only
Contract Number (if available)
Taxpayer Identification Number
(TIN): Enter your social security number (SSN) if an
individual or federal employer identification number
(EIN) if a business.
SSN / EIN:
Name:
Business Name, if different from above:
Provider Name and
Remittance Address:
NOTE: Name must match your social security card
if you are an individual or sole proprietor. All other
businesses must use the name that was used
when your employer identification number was
applied for.
Provider Order Address
Information
Purchase Order
Preferences
Business Structure
Remit Address:
City, State & ZIP:
Remit Phone #:
Company Website/URL:
Order Address:
City, State & ZIP:
Order Contact Name:
Order Phone #:
Order Email Address:
By which method do you prefer to receive purchase orders?
Email
US Mail
Number of
Employees
NAICS Code
(see www.naics.com/search)
Certification: Under penalties of perjury, I certify that:
1)
The number shown on this form is my correct taxpayer identification number, and the name shown is the correct corresponding name.
2)
I am subject to 1099 reporting unless one of the following is checked:
Government Entity.
Tax Exempt Organization.
Corporation that does not provide medical services or billing/collection for medical services.
Other (please specify):
3)
4)
I am a U.S. person (including a U.S. resident alien).
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 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.
Certification Instructions: You must cross out item 4 above if you have been notified by the IRS that you are currently subject to backup
withholding because of underreporting of interest or dividends on your tax return.
Print
and Sign
Here:
Name
Printed:
Title
Signature:
Phone:
Printed:
Date:
HC 573 (06/2015) (BACK)
HENNEPIN COUNTY CONTRACTOR
AFFIRMATIVE ACTION (AA) CLASSIFICATION
The information requested below is used internally by Hennepin County to monitor and report on participation in county
contracting. Your cooperation in completing this form is greatly appreciated.
Vendors who do not complete this information may be contacted by Hennepin County to provide the information requested. If
you have questions completing this side of the form, please call: (612) 348-3181.
1)
Check One:
Publicly held company¹
Non-profit entity
If you chose one of these, STOP HERE.
Government entity
Other
2)
If you chose “Other” please answer all remaining questions
Check One:
Small Business Certified by CERT Program²
NOT a CERT² Certified Small Business
3)
Check One gender of majority owner:
Male
Female
4)
3
Check One ethnicity of majority owner :
Black/African American
Hispanic
Asian or Pacific Islander
American Indian or Alaskan Native
White/Caucasian
¹ A Publicly Held Company is a company whose stock is traded on the open market.
² Small Business Enterprise Certification:
While certification is not necessary to do business with Hennepin County, only CERT certified businesses can be
counted toward the goal for Small Business Enterprise (SBE) participation in county contracting. Certification also
boosts market exposure and qualifies businesses to access SBE program services. For further information about
certification, please call 651-266-8900 or visit the Central Certification Program’s website at: http://cert.smwbe.com.
³ Ethnicity and Gender Definitions:
Black/African American: All persons having origins in any of the Black racial groups of Africa.
Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American descent or other Spanish culture of
origin, regardless of race.
Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the
Indian Sub-continent or the Pacific Islands, including, for example, China, Japan, Korea, Hawaii, Guam, the Philippine
Islands and Samoa.
American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and
who maintain tribal affiliation or community attachment.
White/Caucasian: All persons with origins in any of the original peoples of Europe, North Africa or the Middle East.