PLEASE DO NOT STAPLE Statewide Payee Registration & W-9 Form Washington State STEP 1: Is this a NEW registration or CHANGE to an existing registration (check one)? NEW REGISTRATION (also includes changing the LEGAL NAME, SSN, EIN or reporting type) CHANGE to EXISTING REGISTRATION ­ complete the ENTIRE form and check below what is updated: Business Name/DBA Business Address Contact Information Bank, Routing or Account Numbers Payment Options EXISTING REGISTRATION ­ NO CHANGE ­ there is no change to your tax, banking, or address information. You need to complete only steps 5 &6 of this form. If you know your Statewide Vendor Number, enter it here: SWV: STEP 2: Enter information about the payee and contact person Legal Name of Payee as it appears on federal tax forms EIN or SSN for the Legal Name at left Business Name, if different from Legal Name above ­ e.g. Doing Business As (DBA) Name Contact Person Mailing Address for us to send notifications or payments ­ PO Box or Street Address Title of Contact person ( Mailing Address ­ Suite or Office Number ) ) O Ext. Telephone Number for Contact Person City State Zip + 4 ( / MIPSC / / System / Fax Number for Contact Person 2350 Email for us to use ONLY to send you notifications about your account / / L&I Provider # L&I # Ownership (Above Line for L&I Office Staff Only) STEP 3: Select Payment Option: Direct Deposit to bank (recommended) or Check in US mail Note: Register now for Direct Deposit available at a later date. STEP 4: For Direct Deposit, complete all fields below and sign ( Financial Institution Name ­ must be a US institution ) - Financial Institution Phone Number EXAMPLE Routing Number ­ see example at right Account Number ­ see example at right You may also attach a voided check if you are unsure which number to enter above Account Type: Checking or Savings (Checking will be used if neither box is marked.) routing number (nine digits) account number can vary in length Authorization for Direct Deposit: I hereby authorize and request the Office of Financial Management (OFM) and the Office of the State Treasurer (OST) to initiate credit entries for payee payments to the account indicated above, and the financial institution named above is authorized to credit such account. I agree to abide by the National Automated Clearing House Association (NACHA) rules with regard to these entries. Pursuant to the NACHA rules, OFM and OST may initiate a reversing entry to recall a duplicate or erroneous entry that they previously initiated. I understand that, if a reversal action is required, OFM will notify this office of the error and the reason for the reversal. This authority will continue until such time OFM and OST have had a reasonable opportunity to act upon written request to terminate or change the direct deposit service initiated herein. Authorization Name on Account Title SIGNATURE of Authorization Name on Account Date Page 1 of 2 F800-065-000 Substitute Statewide Payee/W-9 form 08-12 American LegalNet, Inc. www.FormsWorkFlow.com STEP 5: Complete and sign the Request for Taxpayer Identification Number (W-9) Substitute Form W-9 Request for Taxpayer Identification Number and Certification 1. Legal Name (as shown on your income tax return) 2.Business Name, if different from Legal Name above ­ eg. Doing Business As (DBA) Name 3.Check ONLY ONE box below (see W-9 instructions for additional information) Individual or Sole Proprietor Corporation LLC filing as a sole proprietor Partnership S-Corp LLC filing as Partnership LLC filing as S-Corp LLC filing as Corporation Non Profit Organization Volunteer Board /Committee Member Local Government State Government Federal Government (including tribal) Tax-exempt organization Trust/Estate 4. For Corporation, S-Corp, Partnership or LLC, check one box below if applicable: Medical Attorney/Legal (see instructions for W-9 to determine if you are exempt from backup withholding) 5. If exempt from backup withholding, check here: 6. Address (number, street, and apt. or suite no.) 7. City, State, and ZIP code Department of Labor and Industries Attn: Provider Credentialing and Compliance PO Box 44261 Olympia Wa 98504-4261 7.Taxpayer Identification Number (TIN) Enter your EIN OR SSN in the appropriate box to the right (do not enter both) For individuals, this is your social security number (SSN). For other entities, it is your employer identification number (EIN). NOTE: The EIN or SSN must match the Legal Name as reported to the IRS. For a resident alien, sole proprietor, or disregarded entity, or to find out how to get a Taxpayer Identification Number, see the W9 Instructions. If the account is in more than one name, see the W9 Instructions for guidelines on whose number to enter. Social security number - - OR Employer identification number - 8. Certification Under penalty of perjury, I certify that: 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 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 I am a U.S. person (including a U.S. resident alien). (For additional information about the W-9 see the W-9 Instructions.) SIGNATURE of U.S. PERSON Date STEP 6: Submit to ONE of the following: For Medical Providers Provider Network Application (WPA): Non-Network Provider Application: For Crime Victims Licensed Mental Health Counselors FAX: 360-902-4563 FAX: 360-902-4484 FAX: 360-902-5333 For questions contact Provider Credentialing: 360-902-5140 Page 2 of 2 F800-065-000 Substitute Statewide Payee/W-9 Form 09-2012 American LegalNet, Inc. www.FormsWorkFlow.com  Instructions for the Statewide Payee Registration Form The term `payee' refers to an individual or business that received payments from the State of Washington. This form is intended to be used for payees to register with the State of Washington, indicate how they would like to receive payments, and change their registration information. For prompt payment, it is important that we receive complete and accurate information. We must return any form that is not complete, so please be sure to read and follow these instructions carefully. Step 1: Is this a new registration or a change to