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Vendor Information-TIN Certification AO 213 - New York
| Vendor Information-TIN Certification Form. This is a New York form and can be used in Southern District Bankruptcy Court Federal . |
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AO 213 (Rev. 06/12) ADMINISTRATIVE OFFICE OF THE UNITED STATES COURTS Accounting and Financial Systems Division Sensitive Information VENDOR INFORMATION/TIN CERTIFICATION Vendor Address ' Ex-AO Employee ' SAM Vendor (Formerly CCR) (No TIN Certification Required) Other Address (If different from Vendor Address) Select all that apply ' Order ' Remit ' 1099 Address: City: State: Telephone #: Description: (If needed) Select all that apply ' Order ' Remit ' 1099 Name: Business Name: (if different from above) Address 1: Address 2: City: State: Zip Code: Zip Code: Taxpayer Identification #: (TIN, SS, or EIN number) DUNS # Financial Information (If Requested) Bank Name: City: State: Zip Code: Routing # (this nine digit number appears on your checks, but do not include individual check numbers): Account #: Type of Account: (select one) ' Checking ' Savings Type of Organization for 1099 reporting: ' sole proprietorship; ' corporate entity (not tax-exempt); ' health care provider; ' government entity (write in either federal, state or local) Taxpayer Identification Number Certification Under penalties of perjury, I certify that: 1. 2. ' partnership; ' corporate entity (tax-exempt); ' other: The Taxpayer Identification Number listed in the Vendor Address area above is the correct number assigned 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 and dividends, or (c) the IRS has notified me that I am no longer subject to the backup withholding, and I am a U.S. citizen or other U.S. person (defined below). 3. ' You must select this check box 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. If you make a false statement with no reasonable basis that results in no backup withholdings, you are subject to a $500 penalty. Willfully falsifying certifications or affirmations on this form may subject you to criminal penalties including fines and/or imprisonment. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AO 213 (Rev. 06/ 12) Definitions: "Taxpayer Identification (TIN, SS, or EIN number)" is the number required by the Internal Revenue Service (IRS) to be used in reporting income tax and other returns. The TIN may be either a social security number (SSN) or an employer identification number (EIN). "U.S. person" means: ! ! An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States. The TIN, as well as the information above is required in order to comply with debt collection requirements of 31 U.S.C. §§ 7701(c) and 3325(d), reporting requirements of 26 U.S.C. §§ 6041 and 6041A, and implementing regulations issued by the IRS. Failure or refusal to furnish this information may result in 28 percent backup withholding on any payments otherwise due under any awarded contract or purchase order. The TIN may be used by the government to collect and report on any delinquent amounts arising out of the vendor's relationship with the government (31 U.S.C. § 7701(c)(3)). The TIN provided may be matched with IRS records to verify its accuracy. Complete this section only if a TIN was not provided on page one, and select closest reason why not: ' The vendor is a nonresident alien, foreign corporation or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States; ' The vendor is an agency or instrumentality of a foreign government; Additional information required for vendors used for procurement (purchase orders, contracts, etc.) Indicate which, if any, of the following categories are applicable. These categories require that the vendor is 51% owned and the management and daily operations are controlled by one or more members of the selected socio-economic group: ' Not Applicable ' Women Owned Business ' Minority Owned Business (If yes, select one of the owner's race/ethnicity selections from below): ' Asian-Pacific American ' Black American ' Subcontinent Asian (Asian-Indian)American ' Hispanic American ' Native American ' Other: Date: Vendor's signature For Agency Use Only The vendor name and DUNS number is all that is required for registered System for Award Management (SAM) vendors (formerly CCR). (Check www.sam.gov for registration status.) Do not use this form for purchase card merchants. Mark Boxes that apply: ' Addition ' Active ' Change ' Inactive ' Vendor Code: ' Vendor Type: (make entry only if change) The following information is optional for individuals whose name and telephone are already on the form: Contact Name: Telephone Number: Email: Identification of person making this request: Name: Telephone Number: Please type or print clearly. Originating Office: For "AO" FAS4T Users only, e-mail the completed form to: AOdb_OFB_Client Service Desk/DCA/AO/USCOURTS. For questions regarding AOFAS4T the Client Service Desk can be contacted at (202) 502-2242. For "Court" FAS4T Users, send this form to the local Vendor Administrator. For questions regarding Court FAS4T please contact SDSD at (210) 301-6320. This form should be completed with signature by the vendor and submitted by Judiciary staff only. Sensitive information must be securely maintained and only visible to the appropriately designated financial employee. 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