Agenda - 09-20-2022; 8-b - Acceptance of NC Agriculture Development and Farmland Preservation Trust Fund Grant

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REV 01/2019 61 NC Office of the STATE OF NORTH CAROLINA State Controllerrr" M l SUBSTITUTE W-9 FORMS (IRS Form W-9 will not be r accepted in lieu of this form) Request for Taxpayer Identification Number *Denotes a Required Field *1. ❑Social Security Number(SSN), Please select the appropriate Taxpayer Identification Number(EIN,SSN, OR or ITIN)type and enter your 9-digit ID number. The U.S.Taxpayer ❑ Employer Identification Number(EIN), Identification Number is being requested per U.S.Tax Law.Failure to OR provide this information in a timely manner could prevent or delay ❑ Individual Taxpayer Identification Number(ITIN) payment to you or require The State of NC to withhold 24%for backup *2• withholding tax. (PRESS THE TAB KEY TO ENTER EACH NUMBER) *4.Legal Name(as shown on your income tax return): 3. Dunn&Bradstreet Universal Numbering System(DUNS)(see instructions) S.Business Name/DBA/Disregarded Entity Name,if different from Legal Name: (PRESS THE TAB KEY TO ENTER EACH NUMBER) Contact Information C C *6.Legal Address 7.Remittance Address(Location specifically used for payment that is (DO NOT TYPE OR WRITE IN THIS FIELD) different from Legal Address,if applicable) *Address Line 1: Address Line 1: Address Line 2: Address Line 2: L >. *City *State *Zip(9 digit) City State Zip(9 digit) ro CL M *County County f— I *8.Contact Name: *9.Phone Number: +' 10.Fax Number: v V1 11.Email Address: *12.Entity Type "13.Entity 14.Exemptions(see Classification instructions) Individual/Sole Proprietor/Single-member LLC ❑C-Corporation S-Corporation © Medical Services Partnership ❑Trust/Estate ❑Other ❑ Legal/Attorney Exempt payee code(if any): Services ®Limited liability company. Enter the tax classification(C=C corporation, © NC Local Govt S=S corporation, P=Partnership) ❑ Federal Govt Note: Check the appropriate box in the line above for the tax classification of the single- © NC State Agency member owner.Do not check LLC if the LLC is classified as a single-member LLC that is Exemption from FATCA disregarded from the owner unless the owner of the LLC is another LLC that is not ® Other Govt reporting code(if any): disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC ® Other(specify) that is disregarded from the owner should check the appropriate box for the tax classification of its owner. Under penalties of perjury,I certify that: = 1. The number shown on this form is correct taxpayer identification number or I am waiting for a number to be issued to me and p Y ( g ), ++ 2. 1 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 v (IRS)that I am subject to backup withholding because 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 i 3. 1 am a U.S.citizen or other U.S.person(defined later in general instructions),and U4. The FATCA code(s)entered on this form(if any)indicting that I am exempt from FATCA reporting is correct. N Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website(https://www.irs.gov/): *Printed Name: *Printed Title: N *Authorized U.S. *Date: N Signature: Please complete the"Modification to Existing Vendor Records"section below If there have been any changes to the following: Tax Identification Number(TIN), Legal Name,Business Name,Remittance Address Return to the NC State Agency from which you are requesting payment.