Eastern Kentucky University requires a Federal Tax Identification number or Social Security number for all vendors or persons doing business with the University in order to comply with Federal Regulations and tax reporting requirements. Please take a few minutes to fill out this information and return to us to ensure prompt payment of your invoices. Thank you for the valuable service you have provided Eastern Kentucky University, and we look forward to a long and lasting relationship. IF SENDING A W-9, PLEASE RETURN THIS FORM ALSO.
For your convenience, you may return the information one of the following ways:
| EMAIL: adm.purchasing@eku.edu | Eastern Kentucky University Commonwealth 14th Floor #1411 521 Lancaster Avenue Richmond, Kentucky 40475 | |
| Phone # (859)622-2246 Please type or print legibly | VENDOR INFORMATION | |
| Name of Firm * (Company or Individual) | Phone Number* | Make Checks Payable To* |
|---|---|---|
| Address* | Fax Number* | Payment Address* |
| Address | Web Site Address or E-mail | Payment Address |
| Address | Vendor Representative | Name on Invoice* |
| City* State* Zip* | Federal Tax ID Number** | Social Security Number** |
| Willing to accept ACH payments* Yes ☐ No ☐\nBank Name & Routing # ________ | Willing to accept credit card payments*\nYes ☐ No ☐ | Payment Terms* |
| Bank Account # ________ | ||
| * required fields\n**Federal Tax ID Number- This field must be completed if “Name of Firm” is a company name.\nSocial Security Number- This field must be completed if “Name of Firm” is an individual’s name. | ||
| *REGISTRATION\nAny foreign corporation (outside the State of Kentucky) must obtain a certificate of authority from the Secretary of State as is required by KRS 271B.15-010 & KRS/014A06/010\n• Certificate #: ________ (https://secure.kentucky.gov/sos/ftbr/Welcome.aspx)\n• Claimed exemption: ________ | ||
| Any “person” (business or individual) making retail sales in the state are to be registered to collect Kentucky sales and use tax. If the foreign individual (or business) is making retail sales they should be registered for Kentucky sales and use tax purposes by completing a Tax Registration Application (form 10A100), available at the link below. If they are under contract to perform services that do not include the sale of tangible personal property or digital property, or do not perform services subject to tax per KRS 139.200 (such as admissions, provision of telecommunication services, sewer services, and so on), then they are not required to register.KRS 139 • Consumer Use Tax Account number: ________ (http://revenue.ky.gov/) • Sales Tax Account Number: ________ | ||
| 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 no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholdings because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Taxpayer Identification Number. Signature of U.S. Person ________ Date ________ | ||
| *Business Classification Reference Links: www.ccr.gov/sizestandard.asp, https://eweb1.sba.gov/hubzone/internet/general/whoweare.cfm, and | ||
| Type of Ownership (Check Appropriate Box(es))*\n☐ (01) Individual/Sole Proprietorship ☐ (05) Non-Resident Alien ☐ (SM) Small Business ☐ (SD) Small Disadvantaged Business\n☐ (02) Partnership ☐ (06) Exempt from backup ☐ (LG) Large Business ☐ (GA) Government Agency\n☐ (03) Corporation-Incorporated in (State) ☐ Other: ________ | Business Classification (Check Appropriate Box(es))*\n☐ (SM) Small Business ☐ (SM) Small Disadvantaged Business\n☐ (LG) Large Business ☐ (LG) Small Disadvantaged Business\n☐ (CT) In County ☐ (CT) Non-Profit (N) (N) Minor Owned (N) (N) Minor Owned (N) (N) Minor Owned (N) (N) Minor Owned (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) (N) | |
Printed Name of Authorizing Official:
Prin*
Authorized Signature: ___
Date: _____