2023-662-E-DEAPR-North Carolina Department of Agriculture and Consumer Services-Annual Contract Update for NCADFP Grant Contract for matched funds

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NC Office of the State Controller (IRS Form W-9 will not be accepted in lieu of this form) *Denotes a Required Field STATE OF NORTH CAROLINA SUBSTITUTE W-9 FORM Request for Taxpayer Identification Number 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. Section 1– Taxpayer Identification Section 2 -Certification *1. Social Security Number (SSN), OR Employer Identification Number (EIN), OR Individual Taxpayer Identification Number (ITIN) *2. Please select the appropriate Taxpayer Identification Number (EIN, SSN, or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer Identification Number is being requested per U.S. Tax Law. Failure to provide this information in a timely manner could prevent or delay payment to you or require The State of NC to withhold 24% for backup withholding tax. *4. Legal Name (as shown on your income tax return):3. Dunn & Bradstreet Universal Numbering System (DUNS) (see instructions) 5. Business Name/DBA/Disregarded Entity Name, if different from Legal Name: Contact Information *6. Legal Address 7. Remittance Address (Location specifically used for payment that is different from Legal Address, if applicable) *Address Line 1: Address Line 1: Address Line 2: Address Line 2: *City *State *Zip (9 digit) City State Zip (9 digit) *County County *8. Contact Name: *9. Phone Number: 10. Fax Number: 11. Email Address: *12. Entity Type *13. Entity Classification 14. Exemptions (see instructions) Individual/Sole Proprietor/Single-member LLC C-Corporation S-Corporation Partnership Trust/Estate Other___________________________ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ________ Note: Check the appropriate box in the line above for the tax classification of the single- member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. Exempt payee code (if any): Exemption from FATCA reporting code (if any): Under penalties of perjury, I certify that: 1.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 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 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 4.The FATCA code(s) entered on this form (if any) indicting that I am exempt from FATCA reporting is correct. Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/): *Printed Name: *Printed Title: *Authorized U.S. Signature: * Date: Medical Services Legal/Attorney Services NC Local Govt Federal Govt NC State Agency Other Govt Other (specify) N/A Attachment FREV 01/2019 (PRESS THE TAB KEY TO ENTER EACH NUMBER) (DO NOT TYPE OR WRITE IN THIS FIELD) 5 6 6 0 0 0 3 2 7 Orange County P.O. Box 8181 Hillsborough NC 27278 Gary Donaldson 919-245-2453 gdonaldson@orangecountync.gov Local Governmentn Gary Donaldson n n Chief Financial Officer DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 11/15/2023