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U.S. House of Representatives <br /> Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form <br /> Internal Revenue Code 6109,31 U.S.C.3322,31 CFR 210 and the 1996 Debt Collection Improvement Act require all entities that do business with the <br /> United States Government to provide a Tax Identification Number(TIN)and Electronic Funds Transfer(EFT)information for payment. PL 93-579 <br /> protects your privacy and mandates that the information never be published or used for any other purpose than to pay you. Please complete all sections <br /> below,sign and return via the email or fax number listed. <br /> RETURN FORM TO: VendorEFT©mail.house.gov FAX NUMBER: (202)225-6914 <br /> SECTION I UNITED STATES HOUSE OF REPRESENTATIVES INFORMATION <br /> ADDRESS US HOUSE OF REPRESENTATIVES-ACCOUNTING,3110 O'NEILL FEDERAL BUILDING,WASHINGTON,DC 20515 <br /> AGENCY IDENTIFIER 53-6002523 AGENCY LOCATION CODE 4832 TELEPHONE NUMBER (202)226.2277 <br /> SECTION II PAYEE/COMPANY INFORMATION <br /> NAME(AS SHOWN ON YOUR INCOME TAX RETURN) CHECK APPROPRIATE BOX FOR FEDERAL TAX CLASSIFICATION(required) <br /> Individual/ <br /> Sole 0 C Corporation OS Corporation 0 Partnership QTrust/Estate <br /> Proprietor <br /> BUSINESS NAME/DISREGARDED ENTITY NAME or DBA,IF DIFFERENT THAN ABOVE Exempt ❑ <br /> 0 Limited Liability Company Enter tax classification <br /> payee <br /> (C=C corporation,S=S corporation,P=Partnership) <br /> E OF TAX IDENTIFICATION NUMBER ENTER TAX IDENTIFICATION NUMBER ❑OTHER(Other entities.Enter your business name below as shown on required federal tax <br /> SOCIAL SECURITY NUMBER or documents"Name"line.This name should match the name shown on the charter or other legal <br /> 513 <br /> ( ) document creating the entity.You may enter any business,trade,or DBA name on the"Business <br /> EIN name/disregarded entity name"line.) <br /> ADDRESS/CITY/STATE/ZIP <br /> PURCHASE ORDER ADDRESSICITY/STATE/ZIP <br /> CONTACT PERSON NAME <br /> EMAIL EMAIL <br /> TELEPHONE NUMBER 'FAX NUMBER TELEPHONE NUMBER 'FAX NUMBER <br /> REMIT TO ADDRESS <br /> SECTION HI FINANCIAL INSTITUTION INFORMATION <br /> BANK NAME(Branch City,State) <br /> ACH COORDINATOR NAME TELEPHONE NUMBER <br /> NINE-DIGIT ROUTING TRANSIT NUMBER <br /> DEPOSITOR ACCOUNT TITLE <br /> DEPOSITOR ACCOUNT NUMBER LOCKBOX NUMBER <br /> TYPE OF ACCOUNT ❑CHECKING 0 SAVINGS 0 LOCKBOX <br /> SECTION IV SOCIO-ECONOMIC INFORMATION <br /> Type of Business Q Large Business-No Socio-Economic Designations ❑Minority❑SmBusiness 0 Sm-Disadv/Minority ❑Sm-Disadv Only ❑SmMin Only <br /> Sm-Disadvantaged Business Prog ❑8(a)Firm HUBZone Program 0 HUBZone Eligible ❑Emerging Small Business ❑Women-Owned Business <br /> Other Preference Programs 0 Buy Indian 0 Directed to JWOD Non-Profit❑No Preference/Not Listed ❑Small Business Set-Aside ElVery Small Business Set-Aside <br /> Veteran Owned Status ❑Non-Vet Owned SmBus❑Other Vet Owned SmBus ❑Serv-Disabled Vet Other Bus❑Serv-Disabled Vet Owned SB❑Vet-Owned Other Bus <br /> Size of Business ❑(A)50 or less ®(B)51-100 ❑(C)101-250 0(D)251.500 ❑(E)501-750®(F)751-1,000 0(G)Over 1,000 0(M)1 million or less <br /> ❑(N)1.1-2 million D(P)2.1-3.5 million 0(R)3.1-5 million D(S)5.1-10 million 0(T)10.1-17 million 0(Z)Over 17 million <br /> SECTION V CERTIFICATION OF DATA BY PAYEE/COMPANY <br /> NAME TITLE/POSITION <br /> SIGNATURE DATE TELEPHONE NUMBER <br /> USHR 2013 V1 <br />