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62 <br /> NC Office of the STATE OF NORTH CAROLINA <br /> State Controller <br /> SUBSTITUTE W-9 FORM <br /> *Denotes a Required Field y <br /> This form is to be <br /> Modification to Existing Vendor Records <br /> - <br /> completed by the vendor. <br /> This form is to be completed by the vendor if one or more of the following have changed: <br /> 1. Change of remittance address. <br /> 2. Change of Social Security Number (SSN), or Employer Identification Number(EIN), or Individual Taxpayer <br /> Identification Number(ITIN). <br /> 3. Change of Vendor Name. <br /> Please complete the applicable sections below. <br /> Section 1: <br /> CHANGE FROM: Remittance Address CHANGE TO: Remittance Address <br /> *Address Line 1: *Address Line 1: <br /> Address Line 2: Address Line 2: <br /> *City *State *Zip(9 digit) *City *State *Zip(9 digit) <br /> *County *County <br /> NOTE: If you would like to receive your payments electronically, please <br /> complete the Vendor Electronic Payment Form <br /> Section 2: <br /> * CHANGE FROM: SSN, or EIN, or ITIN * CHANGE TO:SSN,or EIN,or ITIN <br /> (PRESS THE TAB KEY TO ENTER EACH NUMBER) (PRESS THE TAB KEY TO ENTER EACH NUMBER) <br /> Section 3: <br /> CHANGE FROM:Vendor Name CHANGE TO:Vendor Name <br /> *Legal Name: *Legal Name: <br /> Business Name/DBA/Disregarded Entity Business Name/DBA/Disregarded Entity <br /> Name, if different from Legal Name: Name, if different from Legal Name: <br /> *Printed Name: *Printed Title: <br /> *Authorized U.S. * Date: <br /> Signature: <br />