OTHER-2022-048-NCADFP Grant Contract

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REV 01 /2019 NC Office of the STATE OF NORTH CAROLINA State Controller SUBSTITUTE W = 9 FORM ( IRS Form W-9 will not be accepted in lieu of this form ) Request for Taxpayer Identification Number �• w ° � * 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 94git 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. ( PRESSE TAB KEY TO ENTER EACH M E * 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 `i'AE KEY TO ENTER EACH NUMBER) Contact Information to *6 . Legal Address 7 . Remittance Address ( Location specifically used for payment that is JNOTTYPE FIELD)WRITETHIS different from Legal Address, if applicable ) s * Address Line 1 : Address Line 1 . C Address Line 2 : Address Line 2 : L >. * City * State * Zip (9 digit) City State Zip (9 digit ) M L M * County County F- 1 r*1 * 8 . Contact Name : * 9 . Phone Number : 10. Fax Number : 11 . Email AddressTT * 12 . Entity Type * 13 . Entity 14 . Exemptions (see Classification instructions) M Individual/Sole Proprietor/Single- member LLC FIC- Corporation F1S- Corporation Medical Services Partnership 17 Trust/Estate Other O 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 ) ri Federal Govt Note : Check the appropriate box in the line above for the tax classification of the single- El 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 El Other Govt reporting code ( if any) : disregarded from the owner for U . S . federal tax purposes . Otherwise, a single- member LLC 117 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 : C1 . 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 a 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 ( 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 3 . I 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. r N Certification instructions : Please refer to the IRS Form W- 9 located on the IRS Website ( https ://www. irs .,ov C * Printed Name : * Printed Title : - } _ G * 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 .