CJA Taxpayer Identification Form

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT CJA TAXPAYER IDENTIFICATION FORM CJA counsel to complete and return to patty_layne@ca4.uscourts.gov if they have not previously received CJA payments from the federal courts or if their information has changed. Please print or type. NAME (as registered for ECF) Last: ______________________________________ Middle: ____________________________________ Prefix (Mr., Ms., Professor): ___________________ FIRM (as registered with IRS) Firm Name: _______________________________________________________________________________ Address (PO Box and Street):__________________________________________________________________ __________________________________________________________________________________________ City, State, Zip Code: ________________________________________________________________________ Phone: (____)___________________ Ext.: ___________ Fax:(____)___________________________ First: _______________________________________ Generation (Jr.,Sr.,II): _________________________ Former Name (if any): _________________________ Email Address: _____________________________________________________________________________________ Has your address or email address changed recently: Yes No Social Security Number (for CJA Database): _____________________________________________________ SELECT INCOME REPORTING OPTION: Report to my Social Security number provided above. Report to my firm's EIN, as provided here: ____________________________________________________ (I have a pre-existing agreement to report income to my firm's Employer Identification number.) __________________________________ (Date) _________________________________________ (Signature) Rev. 04/26/11 American LegalNet, Inc. www.FormsWorkFlow.com