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SUBSTITUTE FORM W-9 <br /> VENDOR REGISTRATION FORM <br /> NORTH CAROLINA DEPARTMENT OF TRANSPORTATION <br /> Pursuant to Internal Revenue Service(IRS)Regulations,vendors must furnish their Taxpayer Identification Number(TIN)to the State.If this number is <br /> not provided,you may be subject to a 20%withholding on each payment.To avoid this 20%withholding and to insure that accurate tax information is <br /> reported to the Internal Revenue Service and the State,please use this form to provide the requested information exactly as it appears on file with the IRS. <br /> INDIVIDUAL AND SOLE PROPRIETOR:ENTER NAME AS SHOWN ON SOCIAL SECURITY CARD <br /> CORPORATION OR PARTNERSHIP :ENTER YOUR LEGAL BUSINESS NAME <br /> NAME: 1z AY�,C- C O J A/T;� <br /> MAILING ADDRESS:STREET/PO BOX: 0 pX 8/-' <br /> CITY,STATE,ZIP: N1 LLf 309'3L)6-1{ NC )—f 2 q ff <br /> DBA/TRADE NAME(IF APPLICABLE): <br /> BUSINESS DESIGNATION: ❑INDIVIDUAL(use Social Security No.) El SOLE PROPRIETOR(use SS No.or Fed ID No.) <br /> ❑CORPORATION(use Federal ID No.) ❑PARTNERSHIP (use Federal ID No.) <br /> ❑ESTATE/TRUST(use Federal ID no.) WSTATE OR LOCAL GOVT.(use Federal ID No.) <br /> ❑OTHER/SPECIFY <br /> SOCIAL SECURITY NO. - - (Social Security#) <br /> OR <br /> FED.EMPLOYER IDENTIFICATION NO. - (Employer Identification#) <br /> COMPLETE THIS SECTION IF PAYMENTS ARE MADE TO AN ADDRESS OTHER THAN THE ONE LISTED ABOVE: <br /> REMIT TO ADDRESS:STREET/PO BOX: <br /> CITY,STATE,ZIP: <br /> Participation in this section is voluntary. You are not required to complete this section to become a registered vendor.The information below will in no way affect the vendor registration process <br /> and its sole purpose is to collect statistical data on those vendors doing business with NCDOT. If you choose to participate,circle the answer that best fits your firm's group definition. <br /> What is your firm's ethnicity?(❑Prefer Not To Answer, ❑African American, ❑Native American, ❑Caucasian American, ❑Asian American, <br /> ❑Hispanic American, ❑Asian-Indian American, ❑Other: ) <br /> What is your firm's ender? ❑Prefer Not to Answer,❑Male,❑Female Disabled-Owned Business? (❑Prefer Not to Answer, ❑Yes,❑No) <br /> IRS Certification <br /> Under penalties of perjury,I certify that: <br /> 1. The number shown on this form is my correct taxpayer identification and <br /> 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 <br /> 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 <br /> 3. I am a U.S.person(including a U.S.resident alien). <br /> The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.For <br /> complete certification instructions please see IRS FORM W-9 at http://www.irs.gov/pub/irs-pdf/fw9.r)d <br /> �d1Ai <br /> NAME(Pant or Type) TITLE(Print or Type) <br /> SIGNATURE DAT9 PHONE NUMBER <br /> To avoid payment delays,completed forms should be returned promptly to your local DOT office. <br />