(Massachusetts Substitute W-9 Form)
Rev. April 2009
Request for Taxpayer
Identification Number and Certification
Completed form should be
given to the requesting
department or the department
you are currently doing
( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2)
Business name, if different from above. (See Specific Instruction on page 2)
Check the appropriate box:
number, street, and apt. or suite no.
: if different from legal address number, street, and apt. or
City, state and ZIP code
City, state and ZIP code
Phone # ( ) Fax # ( ) Email address:
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social
security number (SSN). However, for a resident alien, sole proprietor, or
disregarded entity, see the Part I instruction on
page 2. 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 2.
Note: If the account is in more than one name, see the chart on page 2 for
guidelines on whose number to enter.
Dunn and Bradstreet Universal Numbering System (DUNS))
Social security number
Employer identification number
Part II Certification
Please print or type
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
Services (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
I am an U.S. person (including an U.S. resident alien).
4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No____ Yes _____ If yes, in compliance with the State Ethics
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.
Authorized Signature ► Date ►
Purpose of Form
A person who is required to file an information
return with the IRS must get your correct
taxpayer identification number (TIN) to report, for
example, income paid to you, real estate
transactions, mortgage interest you paid,
acquisition or debt, or contributions you made to
Use Form W-9 only if you are a U.S. person
(including a resident alien), to give your correct
TIN to the person requesting it (the requester)
and , when applicable, to:
Certify the TIN you are giving is correct (or
you are waiting for a number to be issued).
Certify you are not subject to backup
If you are a foreign person, use the
appropriate Form W-8. See Pub 515,
Withholding of Tax on Nonresident Aliens and
What is backup withholding? Persons making
certain payments to you must withhold a
designated percentage, currently 28% and pay to
the IRS of such payments under certain
conditions. This is called “backup withholding.”
Payments that may be subject to backup
withholding include interest, dividends, broker and
barter exchange transactions, rents, royalties,
nonemployee pay, and certain payments from
fishing boat operators. Real estate transactions
are not subject to backup withholding.
If you give the requester your correct TIN, make
the proper certifications, and report all your
taxable interest and dividends on your tax return,
payments you receive will not be subject to
backup withholding. Payments you receive will
be subject to backup withholding if:
You do not furnish your TIN to the
You do not certify your TIN when required
(see the Part II instructions on page 2 for
The IRS tells the requester that you furnished
an incorrect TIN, or
The IRS tells you that you are subject to
backup withholding because you did not
report all your interest and dividends only), or
5. You do not certify to the requester that you are
not subject to backup withholding under 4 above
(for reportable interest and dividend accounts
opened after 1983 only).
Certain payees and payments are exempt from
backup withholding. See the Part II instructions
on page 2.
Failure to furnish TIN. If you fail to furnish your
correct TIN to a requester, you are subject to a
penalty of $50 for each such failure unless your
failure is due to reasonable cause and not to
Civil penalty for false information with respect
to withholding. If you make a false statement
with no reasonable basis that results in no backup
withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information.
Willfully falsifying certifications or affirmations
may subject you to criminal penalties including
fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses
TINs in violation of Federal law, the requester may
be subject to civil and criminal penalties.
MA- W-9 (Rev. April 2009)