Wyoming > Workers Compensation
New Registration WOLFS 109A - Wyoming
| New Registration Form. This is a Wyoming form and can be used in Workers Compensation . |
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STATE OF WYOMING WOLFS-109(a) The State of Wyoming must have a properly completed form before payment will be made. PLEASE RETURN THIS FORM TO STATE AGENCY CONTACT STATE AGENCY INFORMATION Agency #, Agency Name, Contact Name, Title, Address; Phone # 053-DWS, Sue R., CBC, Ext 6283 Mail to: Workers' Compensation Division 1510 East Pershing Blvd Cheyenne, WY 82002 Print or type - See Specific Instructions on page 2. The State of Wyoming has adopted the W-9 Form, adding a Wyoming heading and Part 5 for EFT payment. PART 1: Vendor Information Individual or Legal Business Name (Name as shown on your income tax return How are you registered with the IRS? If using SSN #, name should be same as SSN card) Business name: Doing Business As (DBA) - (Only if applicable) Primary Address (Address where Form 1099 should be mailed) Address City Type of Business (Are you or your business providing medical services or legal services?) State/Province Zip Code (+4 if known) PART 2: Taxpayer Identification Number (TIN) Taxpayer Identification Type (TIN = FEIN or SSN): (Check appropriate box below then enter FEIN or SSN in boxes to the right.) Federal Employer Identification Number (FEIN) OR Social Security Number (SSN) Enter TIN HERE (FEIN or SSN) Do Not Use Dashes PART 3: Business Designation/Ownership Type (Select only one box in the Part 3 section below) Corporation Partnership Individual Limited Liability Company (LLC): Sole Proprietor State Government Trust or Estate Other Government Not for Profit OR Corporation Partnership Foreign Corporation or Entity Please fill out IRS form W-8BEN form PART 4: Certification Under penalties of perjury, I certify that: 1. 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 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 not longer subject to backup withholding AND 3. I am a U.S. citizen or other U.S. person (defined below). Preparer's Name (Please Print) Signature of U.S. person Email (if available) Preparer's Title (required for business entities Please Print) Date Telephone Number ( ) - PART 5: DIRECT DEPOSIT (EFT) AUTHORIZATION: Attaching a copy of a voided check from your checking account or a bank certification letter with your account information authorizes payment to you by EFT. Check appropriate box (Check only one box): Checking Account Attach a copy of voided check. Savings Account Attach a signed letter from the Bank Representative of the individual's bank. American LegalNet, Inc. www.FormsWorkFlow.com ATTACH HERE COPY OF VOIDED CHECK or SIGNED BANK LETTER Wyoming Substitute Form W-9 Instructions The State of Wyoming must obtain your correct taxpayer information that will be used to determine whether you will receive a Form 1099 for payments made to you by an agency of the State of Wyoming. This taxpayer information is collected on the Wyoming Substitute Form 109a, and includes a Taxpayer Identification Number (TIN), IRS Name, and other related information. The information provided on this form must match the information on file with the Internal Revenue Service (IRS) for Federal income tax reporting. All vendors doing business with the State of Wyoming must complete the Substitute Form 109a. Vendors located outside the United States that do not have a TIN issued by the U.S. Government should fill out IRS Form W8BEN. Part 1: Vendor Information 1. Individual or Legal Business Name: This should be the name as it appears on your Federal income tax return or how you are set-up or registered with the IRS. This may be either an individual name or a business name. Do not abbreviate names unless they are registered that way with the IRS. If reporting under a SSN number, name should match Social Security Card. 2. Business Name: Doing Business As (DBA): List any "Doing Business As" names that will be doing business with the State of Wyoming. If you do not have DBAs, leave this field blank. 3. Primary Address: This is the address where Form 1099s and any other related correspondence should be mailed. 4. Type of Business: Specify the type of service you or your business provides. Please specify if you or your business provides medical services or legal services. Part 2: Taxpayer Identification Number (TIN) 1. Taxpayer Identification Type: Select the appropriate box to indicate whether the TIN you have provided is your SSN or FEIN. 2. Enter TIN Here: Enter either your Social Security number (individuals) or your Federal Employer Identification Number (FEIN). Do Not include dashes. Part 3: Business Designation/Ownership Type 1. Business Designation: Select the appropriate box. How are you registered with the IRS? If you are unsure of which box to check, contact your income tax preparer for assistance. Part 4: Certification 1. Preparer's Name: Who is the person filling in the information on this form? Fill in the preparer's name, title, signature, email address (if available), date and phone number. The preparer should be an executive of the organization and someone who can answer questions that may arise relating to the Substitute Form 109a. Part 5: Direct Deposit (EFT) Authorization 1. Voided Check/Bank Certification Letter: Check the appropriate box, Checking Account or Savings account. Select only one. Attach a copy of a voided check from your checking account OR a bank certification letter with your account information, authorizing payment to you by EFT. A bank certification letter should contain your vendor name, ABA routing number, account number, account type (checking or savings), and be signed by the bank representative. Please send form to the State Agency you are doing business with. American LegalNet, Inc. www.FormsWorkFlow.com General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. per
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