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NC Office of the <br />State Controller <br />*Denotes a Required Field <br />This form is to be <br />completed by the vendor. <br />STATE OF NORTH CAROLINA <br />SUBSTITUTE W-9 FORM <br />Modification to Existing Vendor Records <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 />Section 2: <br />*CHANGE FROM: SSN, or EIN, or ITIN *CHANGE TO: SSN, or EIN, or ITIN <br />Section 3: <br />CHANGE FROM: Vendor Name CHANGE TO: Vendor Name <br />*Address Line 1: <br />Address Line 2: <br />*City *State *Zip (9 digit) <br />*County <br />*Address Line 1: <br />Address Line 2: <br />*City *State *Zip (9 digit) <br />*County <br />*Legal Name:*Legal Name: <br />Business Name/DBA/Disregarded Entity <br />Name, if different from Legal Name: <br />Business Name/DBA/Disregarded Entity <br />Name, if different from Legal Name: <br />*Printed Name:*Printed Title: <br />*Authorized U.S. <br />Signature: <br />*Date: <br />NOTE: If you would like to receive your payments electronically, please <br />complete the Vendor Electronic Payment Form <br />(PRESS THE TAB KEY TO ENTER EACH NUMBER) (PRESS THE TAB KEY TO ENTER EACH NUMBER) <br />DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2