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Form W"9
(Caober 19&3)
Department of the Treasury
Internal Revenue Service
Please complete this form and return to:
Payer's Request for Taxpayer
Identification Number
Weld County Accounting
ATTN: Payroll
P.O. Box 758
Greeley, CO 80632
Plan• print or type
Address
Name as shown on ac aunt p joint account. also give joint owner's name)
bairc, , A. -(19 i5
q.o I 5,ua-ivovr.ct .I.
City, Stale, and ZIP code
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List account number(s) here (See Instructions) ►
PART I. —Taxpayer Identification Number
Enter the taxpayer identification number in the
appropriate box. For most individual taxpayers,
this is the social security number.
Note: If the account is in more than one name.
see the chart on page 2 for guidelines on which
number to give the payer.
Social security number
59, 3 )
OR
Employer identification number
PART II. —Backup Withholding On
Accounts Opened After
12/31/83
Check the box if you
are NOT subject., to
backup withholding
under the provisions of
section 3406(a)(1XC)
of the Internal Revenue
Code
(See Highlight below.)
Certification. —Under the penalties of perjury, I certify that the information provided on this form is true, correct, and complete.
Signature ►
Instructions (Section re
.Highlight for Interest or Dividend Accounts Opened After
12/31/83 —Backup Withholding
You may be notified that you are sublect to backup withholding under
section 3406(aX1XC) because you have underreported interest or
dividends or you were required to but failed to file a return which would
have included a reportable interest or dividend payment. If you have NOT
been so notified, check the box ii. PART I1. Note: Backup withholding may
apply to existing accounts as well as accounts opened after December 31,
1983. •
Caution: There are other situations where you may be subject to.backup
withholding. Please read the instructions below carefully. •
Purpose of Form
Use this form to report the taxpayer identification number (TIN) of the
record owner of the account to the payer (or broker)
Beginning January 1, 1984. payers must generally withhold 20% of
taxable interest, dividend, and certain other payments if you lad to furnish
payers with the correct taxpayer identification number (this IS referred to as
backup withholding). For most individual taxpayers, the taxpayer
identification number is the social security number.
To prevent backup withholding on these payments, be sure to notify
payers of the correct taxpayer identification number and. for accounts you
open after December 31. 1983. properly certify that you are not subject to
backup withholding under section 3406(ax1XC).
You may use this form to certify that the taxpayer identification number
you are giving the payer is correct and. for accounts opened after
December 31, 1983. that you are not subject to backup withholding:
If the payer provides a different form than Form W-9 to request the
taxpayer identification number, please use it.
Backup Withholding
You are subject to backup withholding it:
(1) You fail to furnish your taxpayer identification number to the payer, OR
(2) The Internal Revenue Service notifies the payer that you furnished an
incorrect taxpayer identification number, OR
(3) You are notified that you are subject to backup withholding (under
section 3406(ax 1 XC)), OR
(4) For an interest or dividend account opened after December 31.
. 1983. you fail to certify to the payer that you are not subject to backup
withholding under (3) above, or faille, certify your taxpayer identification
numl,er.
For payments other than interest or dividends, you are subject to backup
withholding only if (1) or (2) above applies.
trice: are to the kite
Revenue Code.)
Date ►
kb/7
Payments of Interest, Dividends, and Patronage
Dividends
Accounts Opened Before January 1, 1984
To certify that the taxpayer identification number is correct for accounts
opened before January I. 1984, fill out your name and address, enter your
account number(s) (if applicable), complete Part I. sign and date the form
and return it to the payer.
Accounts Opened After December 31, 1983
To certify that the taxpayer identification number is correct and that you are
not subject to backup withholding under section 3406(a)(1)(C) for accounts
opened after December 31. 1983. fill out your name and address. enter
your account numbers) Of applicable). complete Parts I and II, sign and
_date the form and return it to the payer.
If you are subject to backup withholding and are merely providing your
correct taxpayer identification number to the payer, (ill out your name,
address. enter your account number(s) (if applicable), and complete Part I.
Other Payments
II you are merely providing your correct taxpayer identification number to
the payer for payments other than interest, dividends, and patronage
dividends, you need not sign this form. Fill out your name and address.
enter your account numbers) (if applicable). complete Pad 1 and return
the form to the payer.
Account Numbers
If you have more than one account with the same payer (forexample, a
savings account and a certificate of deposit at the same bank), the payer
may request a separate Form W-9 for each account depending on how the
payer's records are kept.
What Number to Give the Payer
Give the payer the social security number or employer identification
number of the record owner of the account. If the account belongs to you
as an individual, give your social security number. If the account is in more
than one name or is not in the name of the actual owner, see the chart on
page 2 for guidelines on which number to report. Obtaining a Number
If you don't have a taxpayer identification number or you don't know your
number, obtain Form SS -S, Application for a Social Security Number Card,
or Form 55.4, Application for Employer Identification Number, at the local
office of the Social Security Administration or the Internal Revenue Service
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