Print current page
Print all pages
Close
1. Provider
|
2. Referral
|
3. Practice
|
4. Education
|
5. License/Certification
|
6. Insurance
|
7. Work History
8. EAP Counselor
|
9. Disability Provider
|
10. FFD Specialist
|
11. Provider Profile
|
12. Attestation
|
13. W-9
13. Substitute for Form W-9 Request for Taxpayer Identification Number
Pursuant to Internal Revenue Service Regulations, you must furnish your Taxpayer Identification Number (TIN) to
ValueOptions
. If this number is not provided, you may be subject to a 31% withholding on each payment. To avoid this 31% withholding and to insure that accurate tax information is reported to the Internal Revenue Service, please use this form to provide the requested information.
If you are an
individual
, you must furnish your individual name as shown on your social security card. If you have changed your last name, for instance, due to marriage, without informing the Social Security Administration of the name change, and you are billing using your Social Security number, please enter your first name, the last name shown on your Social Security card, and your new last name.
If you are a
sole proprietor
, you must furnish your individual name as shown on your Social Security card, and
either
your SSN or EIN (Employer Identification Number). You may also enter your business name or "doing business as" name on the business name line.
Please use the
Add W-9 Form
button to enter the required information.
Substitute for Form W-9
No records are currently attached to this provider
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Date:
(MM/DD/YYYY)
Signature
OR
Date:
(MM/DD/YYYY)
Name
of the person completing the form
© 2012 ValueOptions
®
ProviderConnect
v3.27.00
