HomeMy Public PortalAboutCOTI W-9 with SAVE affidavit (003).pdfFomi W-9
(Rev. October 2004)
Department •_.f the Treasury
Inr.nnel R.wenue c vie:,
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as reported on your inoome tax return)
Business name. if different from above
Individual/
Check appropriate box: ❑ Sole proprietor ❑
Corporation
❑ Partnership
❑ Other ► ._
Exempt from backup
❑ withholding
Address (number. street, and apt. or suite no.)
Requecter's name and addres. (optional)
City. stat?, and ZIP code
List account number(s) here (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
backup withholding. For individuals. this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page .3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number
to enter.
Part II
Certification
Social security number
1141+111
or
Employer identification number
14-111111
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 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 backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
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 of 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. (See the instructions on page 4.)
Sign
Here
Signature of
U.S. person
Date IP -
City of Tybee Island, PO Box 2749, Tybee Island, GA 31328
912-786-4573 I (fax) 912-786-9465
What do products/services do you provide to the City of Tybee Island:
To whom shall we direct the Purchase Order?
Sales Contact: Email:
Phone# Fax#
Location:
To whom shall we direct Payment?
A/R Contact: Email:
Phone# Fax#
Remittance Address:
Our terms are Net 30.
Affidavit Verifying Status
for City Public Benefit Application
By executing this affidavit under oath, as an applicant for a City of Tybee Island, Georgia, Business License or Occupation Tax
Certificate, Alcohol License, Taxi Permit, Contract, or other public benefit as referenced in O.C.G.A. Section 50-36-1, I am stating the
following with respect to my application of a City of Tybee Island:
• Business License or Occupational Tax Certificate,
• Alcohol License,
(circle all that apply)
• Taxi Permit,
• Contract
• Other public benefit
for (printed name of natural person applying on behalf of
individual, business, corporation, partnership, or other private entity).
I) I am a United States citizen.
OR
2) I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-immigrant under
the Federal Immigration and Nationality Act, 18 years of age or older and lawfully present in the United States. *
In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or
fraudu;ent statement or representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of the Official Code of
Georgia.
SUBSCRIBED AND SWORN BEFORE ME ON THIS
THE _ _.._ DAY OF , 20
Notary Public
My Commission Expires:
Signature of Applicant
Date
Printed Name
* Alien Registration Number for Non -citizens
Note: 0. C.G.A. § 50-36-1(e)(2) requires that aliens under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended,
provide their alien registration number. Because legal permanent residents are included in the federal definition of "alien", legal
permanent residents must also provide their alien registration number. Uualifted aliens that do not have an alien registration number
may supply another identifying number below: