SUBSTITUTE W-9 & VENDOR INFORMATION FORM. GIVE FORM TO THE REQUESTER.
DO NOT SENT TO IRS
Submit completed form via mail:
5151 Park Avenue, Fairfield, CT 06825
NEW VENDOR EXISTING VENDOR
Attention: Purchasin
or Fax
203
365-7609
PART I: VENDOR INFORMATION (Please print or type information )
OREIGN ENTITY PLEASE USE FORM W-8 ECI OR W-8 BE
1
2
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4
Exemptions(codes apply only to certain entities, not individuals)
Exemption payee
S Corporation Trustee/estate code(if any)
roprietor or single-member LLC Exemption from FATC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
reporting code(if any)
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above
for the tax classification of the single-member owner.
Other
5
ORDER ADDRESS(no., street, and apt. or ste#) REMITTANCE ADDRESS(no., street, and apt. or ste#)
6 Taxpayer Identification Number (TIN)
SOCIAL SECURITY NUMBER
OR EMPLOYER IDENTIFICATION NUMBER
CITY, STATE and POSTAL CODE CITY, STATE and POSTAL CODE
7
SACRED HEART UNIVERSITY STAFF NAME
SACRED HEART UNIVERSITY STAFF EMAIL
PURCHASE ORDER FAX NUMBER
SACRED HEART UNIVERSITY STAFF PHONE
8 Sacred Heart University Prefers Electronic Forms of Payment:
Do you accept credit card payments? Do you accept other electronic payments? Are you a current Sacred Heart University Student?
YES NO YES NO YES NO
9 Are the services for which payments are received reported for the purpose of self employment tax?
YES NO
Are you aware of a Conflict of Interest, including but not limited to relatives employed by Sacred Heart?
YES NO
PART II: Certification - REQUIRED FOR U.S. ENTITIES AND CITIZENS
Under penalties of perjury, I certify that:
1 The number shown on this form is my correct tax identification number (or I am waiting for a number to be issued to me); an
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 as a result of a failure to report all interest or dividends, or c) the IRS has notified me that I am no longer subject to
ackup withholding; an
3 I am a U.S. citizen or other U.S. person; an
4 The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have
failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment o
secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not
required to sign the certification, but you must provide your correct TIN.
SIGN HERE:
PART III: Contact Information - Individual Authorized to Represent the Vendor
Vendor Contact Person Name Title
Contact Person Email Address Contact Person Phone Numbe
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION
NAME (as shown on your income tax). Name is required on this line; do not leave this line blank.
Business name/disregarded entity name, if different from above
Individual/sole C Corporation Partnership
Signature Date
Print Name
PURCHASE ORDER EMAIL
