STARK COUNTY
REQUEST FOR TAXPAYER IDENTIFICATION FORM
NAME___________________________________________________________________
(IF PART OF A CORPORATION, PLEASE LIST ITS NAME RATHER THAN THE INDIVIDUAL PROVIDING THE SERVICE)
ADDRESS______________________________________________________________________
CITY, STATE AND ZIP CODE______________________________________________________
TAXPAYER IDENTIFICATION NUMBER:
INDIVIDUAL SOCIAL SECURITY NUMBER
__________________________
GROUPS, PARTNERSHIPS, EMPLOYER IDENTIFICATION UMBER
CORPORATIONS, ETC. __________________________
ARE YOU A CORPORATION: YES_______ NO________
PAYMENTS ARE TO BE MADE FOR: (CHECK ONE)
GENERAL SERVICE____ MEDICAL____ RENT____ LAND PURCHASE____ OTHER____
EASEMENT____
IF OTHER, PLEASE DESCRIBE WHAT PAYMENT IS FOR ___________________________
_______________________________________________________________________________
_______________________________________________________________________________
CERTIFICATION:
1. THE NUMBER SHOWN ON THIS FORM IS MY CORRECT IDENTIFICATION NUMBER.
2. AS OF THIS DATE, I HAVE NOT BEEN NOTIFIED BY THE INTERNAL REVENUE
SERVICE THAT I AM SUBJECT TO BACKUP WITHHOLDING.
DATE_____________ SIGNATURE_______________________________
NOTE: PAYMENT WILL BE DELAYED UNTIL COMPLETED FORM
IS RETURNED.
