W9 - Urgent Care Association

W-9 Request for Taxpayer Identification Number and Certification (IRS)

To learn more about Form W-9, click here.

Why are you submitting W-9 Information? *

I am a speaker or other content contributor.
CAUCQ has requested
Other

How would you like to submit your information? *

I will upload a completed W-9 form
I want to enter my information online

To download a blank Form W-9 from the IRS, click here.

Upload your completed Form W-9 *

Click or drag a file to this area to upload.

Detailed instructions for completing the Form W-9 from the IRS can be found on the for itself , click here to view.

1. Name of entity/individual. *

For a sole proprietor or disregarded entity, enter the owner's name.

2. Business name/disregarded entity name, if different from above.

3a. Check the appropriate box for federal tax classification of the entity/individual whose name is entered. *

Individuals/sole proprietor
C corporation
S corporation
Partnership
Trust/estate
LLC
Other

If you check Other

See instructions on Form W-9.

Choose the tax classification for LLC *

C = C corporation
S = S corporation
P = Partnership

If a disregarded entity, instead check the appropriate box for the tax classification of its owner.

3b. Check if you have any foreign partners, owners, or beneficiaries

Foreign partners, owners, or beneficiaries

If you have foreign partners, owners, or beneficiaries

See instructions on Form W-9.

Part above. ZIP

4. Exemptions

Codes apply only to certain entities, not individuals; see instructions on page 3.

Enter exempt payee code (if any)

Codes apply only to certain entities, not individuals.

Enter exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)

Applies to accounts maintained outside the United States.

5. Address (number, street, and apt. or suit no.) *

6. City, state, and ZIP code *

7. List account number(s) here (optional)

Part 1 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 generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other entities, it is your employer identification number (EIN).

Which taxpayer identification number will you enter? *

Social security number
Employer identification number

Enter social security number *

XXX-XX-XXXX

Enter employer identification number *

XX-XXXXXXX

Part II Certification

Under penalties 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 wihholding 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. citizen or other U.S. person; and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification *

Under penalties 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 wihholding 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. citizen or other U.S. person; and The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

I certify and sign this document electronically by typing my name below *

Enter your name

Date of Cerification

Enter todays date

Email *

W-9 Request for Taxpayer Identification Number and Certification (IRS)

If you check Other

If you have foreign partners, owners, or beneficiaries

4. Exemptions

Part 1 Taxpayer Identification Number (TIN)

Part II Certification

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