1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com FEDERAL TAXPAYER IDENTIFICATION NUMBER REQUEST FINANCE DIVISION SFN 53043 (05/2008) W9 Substitute Form 1. INFORMATION **Enter your tax identification number into the appropriate box. This is the number reported to the IRS** Tax Payer Identification Number (TIN) Social Security Number (SSN) OR Legal Name of Business (Note: Name needs to match EXACTLY with the name filed with IRS) Doing Business As (DBA) Payments Address City State Zip Code State Zip Code Physical Address City Telephone Number Fax Number E-Mail Address 2. TYPE OF BUSINESS Corporation Partnership Individual/Sole Proprietor Other EXEMPT from backup withholding. 3. WHAT IS THE NATURE OF YOUR BUSINESS? (Example…..Medical Clinic, Chiropractic Clinc, Law firm, Hospital, School….etc.) 4. AFFADAVIT By completing, signing, and filling this form the business payee applicant: (1) certifies that the person signing this document is a duly authorized officer of this company and that the information given above is current and true to the best of their knowledge and in no way misleading; (2) ensures that correct information will be immediately forwarded to WSI should any data change in the future. 5. IRS FORM W-9 CERTIFICATION Under penalties of perjury, I certify that: If Exempt, Indicate Type of Entity: 1. The number shown on this form is my correct taxpayer identification number, and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, (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). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. 6. SIGNATURE Please print name Date Signature Title American LegalNet, Inc. www.FormsWorkFlow.com W9 Substitute Form Federal Tax Identification Number Request Instructions The following instructions are to assist in the completion of this form. All of the following sections are mandatory and require completion. If all sections are not completed the form will be returned for completion. 1. Information: a. Tax Payer Identification Number (TIN) or Social Security Number (SSN): Fill in with appropriate tax identification number that has been assigned to you by the IRS or social security number if a sole proprietorship. b. Legal Name: Fill in with the name of your business as shown on your income tax return. c. Doing Business as: (D.B.A) or also known as (A.K.A): If your business operates under another name, state that name. d. Payments Address: Fill in the address where you want payments mailed to. e. Physical Address: Fill in if different from Payments Address. f. Telephone Number: Fill in the telephone number for the principle place of business. g. Fax Number: Fill in the fax number for the principle place of business. 2. Type of Business: Check the appropriate box that describes how your business is organized for tax purposes. 3. What is the nature of your business? Indicate the type of business, such as, Medical Clinic, Hospital, Law Firm, Manufacturing, Construction…etc.) 5. W-9 Certification: This certification is copied from the W-9. Check the following Web site for verification: http://www.irs.gov/pub/irs-pdf/fw9.pdf.. If you are not able to access the IRS Web site refer to 2007 Instruction for Form 1099-Misc. (Revised April 2007). . 6. Signature: Please sign to verify all information is correct. Complete, Sign, and Mail to: Workforce Safety and Insurance 1600 E Century Ave. Ste 1 PO Box 5585 Bismarck, ND 58506-5585 Telephone Number: 701-328-3800 Toll Free Fax Number: 701-888-786-8695 TDD Number (for the hearing impaired only) (701)-328-3786 www.WorkforceSafety.com American LegalNet, Inc. www.FormsWorkFlow.com