PAYEE REGISTRATION & SUBSTITUTE IRS FORM W9 FINANCE DIVISION SFN 53043 (07/2014) 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 New registration (includes changes to legal name, taxpayer identification number, social security number) Change to existing registration (complete parts of the form relevant to the change) WSI claim number Internal use only SECTION 1 - Request for taxpayer identification number information Legal name (exact name as filed with IRS or SSA; any variation in name or TIN will cause a delay in processing) Doing Business As (DBA) (information must match billing statement; medical provider information must match CMS 1500 box 33 or UB 04 box 2) Taxpayer identification number (TIN) - Provide only one Employer identification number Tax classification Corporation Other Or Business National Provider Identifier (NPI) number (medical provider only) Social security number - Partnership Individual/Sole Proprietor Exempt from backup withholding Remittance address (address where payments should be sent) Street address Telephone number PO Box (if applicable) City Fax number State Zip code Physical location address (physical address where services are rendered, if different from remittance address) Street address Telephone number City Fax number State Zip Code Correspondence address (address where correspondence should be sent) Street address Telephone number PO Box (if applicable) City Fax number State Zip Code Contact information Contact name (person completing form) Telephone number Title Fax number Affidavit By completing, signing, and filing this form the business payee applicant (1) certifies that the information given above is current and true to the best of their knowledge and is no way misleading; (2) ensures that the correct information forwarded to WSI should any data change in the future. Certification Under penalties of perjury, I certify that (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 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 (3) I am a U.S. person (including a U.S. resident alien) The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding Signature of authorizing agent Date American LegalNet, Inc. www.FormsWorkFlow.com SECTION 2 - Payee type (Please select the primary payee type) Medical Agencies Community/Behavioral Health Home Health Hospice Care In Home Supportive Care Ambulatory Health Care Facilities Ambulatory Surgical Center Chiropractic Clinic Clinic/Center Dental Clinic Hearing and Speech Clinic Massage Therapy Clinic Mental Health Clinic Optometry Clinic Physical Therapy Clinic Podiatric Clinic Radiology/MRI Center Hospitals Hospital Laboratories Clinic Medical Laboratory Physiological Laboratory (IDTF) Nursing & Custodial Facilities Nursing & Custodial Care Facility Other Service Providers Lodging Suppliers DME & Medical Supplies Hearing Aid Equipment Pharmacy Prosthetic/Orthotic Supplier Transportation Services Ambulance Bus/Taxi Miscellaneous Agency Attorney Clerk of Court Collection Agency Court Reporter Funeral Home Insurance Company Moving/Van Line Physical Fitness Program Private Investigator Records Copying Service Retail Service School Sheriff Travel Agency Other SECTION 3 - Sign up for medical provider electronic communications If you would like to receive WSI provider news communications by e-mail, sign up below. Contact Name E-Mail Address SECTION 4 - Submission of form Return completed form (both pages) to: Workforce Safety & Insurance PO Box 5585 Bismarck ND 58506-5585 Fax 701-328-3820 Email ndwsi@nd.gov For questions, contact WSI Customer Service 1-800-777-5033 or 701-328-3800 American LegalNet, Inc. www.FormsWorkFlow.com Payee Registration Substitute IRS Form W9 Instructions Purpose of Form The State of North Dakota is required to obtain your correct taxpayer identification number (TIN) to file an information return with the IRS. Do not send these instructions with your completed form. SECTION 1 Request for taxpayer identification number information Legal name Individuals: Fill in the name as shown on your income tax return. Businesses: Fill in the name as shown on your business IRS filing. Doing Business As (DBA) Individuals: Leave blank Businesses: If your firm operates under another name state it here. Business National Provider Identifier (NPI) number Enter NPI of business as registered with National Plan & Provider Enumeration System (NPPES). Taxpayer identification number Individuals: Enter the social security number (SSN) that matches the legal name. Sole Proprietor: Enter the social security number (SSN) or Employer identification number that matches the legal name. All Other Businesses: Enter the Employer identification number that matches the legal name. Tax classification Check the IRS tax classification box that matches the legal name entered on this form. Remittance address Enter the address where payments should be sent. Physical location address Enter the physical address where services are rendered. Correspondence Address Enter the address where correspondence should be sent. Contact Information: Enter the contact person for information provided on this form. Affidavit Please read the affidavit thoroughly. This paragraph explains what your signature authorizes. Certification This certification is copied from the IRS Form W9. Check the following website for verification and further clarification: http://www.irs.gov/pub/irs-pdf/fw9.pdf Signature of authorizing agent Establishes that you are a U.S. person, or resident alien with authority to make changes as designated on this form for this bidder profile. This application will be rejected if not authenticated accordingly. SECTION 2 Payee type Identify the type of business, i.e. medical or miscellaneous. If medical, select all applicable types. SECTION 3 Sign up for medical provider electronic communications Indicate your consent to receive electronic communication and provide co