In order to comply with Internal Revenue Service (IRS) regulations, we require taxpayer identification information. This information will be used to determine whether you will receive a Form 1099 for payment(s) made to you by an agency of the State of Florida, and whether payments are subject to Federal withholding. The information provided below must match the information that you provide to the IRS for income tax reporting. Federal law requires the State of Florida to take backup withholding from certain future payments if you fail to provide the information requested.

 

* Required

PART 1

IRS Name: * Doing Business As Name:

(first 40 characters exactly as shown on your tax return)

* Primary Address Information (Address where Form 1099 should be mailed)

United States (Includes U.S. Possessions & APO/FPO/DPO)

Foreign Country

Attention of: In Care of:

Address: * City: *

State: * Zip Code: * -
Province / : Postal Code:

State

Country: *

PART 2

* Business Designation

    (click here for Business Designation definitions)

C Corporation	Nonresident alien	Indian Tribal Government
S Corporation	Partnership	Non-Corporate Rental Agent
Government Entity	Limited Liability Company Pick One Disregarded Entity	Individual
Foreign Corporation or Entity	Sole Proprietor	Trust or Estate
Not for Profit

PART 3

Certification Statement

    (click here for Backup Withholding explanation)

Under penalties of perjury, I certify that:

1.   The number shown on this form is my correct taxpayer information AND

2.   I am subject to backup withholding OR

      I am not - subject to backup withholding because:
              (a) I am exempt from backup withholding
              (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result
                  or failure to report all interest or dividends, or
              (c) the IRS has notified me that I am no longer subject to backup withholding AND

3. I am a U.S. citizen or other U.S. person (including U.S. resident alien)

Certification Instructions: To certify the statement above, complete your information below, as preparer, and then re-enter your password to
submit your electronic signature.

Preparer's Name: * Preparer's Title:    

(first last) (required for business entities)

Telephone Number: * Extn:

Email: *




Password: *