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U.S. House of Representatives <br /> Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form <br />INSTRUCTIONS <br />FAX NUMBER:(202) 225-6914 <br />SECTION I UNITED STATES HOUSE OF REPRESENTATIVES INFORMATION <br />ADDRESS US HOUSE OF REPRESENTATIVES - ACCOUNTING, 3110 O'NEILL HOUSE OFFICE 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 />BUSINESS NAME/DISREGARDED ENTITY NAME OR DBA, IF DIFFERENT THAN NAME <br />ON YOUR INCOME TAX RETURN <br />ADDRESS/CITY/STATE/ZIP Enter the correct Tax Identification Number type <br />SOCIAL SECURITY NUMBER (SSN) EMPLOYER TAX ID NUMBER (EIN) <br /> CONTACT PERSON NAME PURCHASE ORDER ADDRESS/CITY/STATE/ZIP <br />PO EMAIL <br /> TELEPHONE NUMBER FAX NUMBER TELEPHONE NUMBER FAX NUMBER <br /> REMIT TO ADDRESS <br />CHECK APPROPRIATE BOX FOR FEDERAL TAX CLASSIFICATION (required) <br />Partnership Trust/Estate C Corporation <br />SECTION III FINANCIAL INSTITUTION INFORMATION <br />BANK NAME TELEPHONE NUMBER <br />NINE-DIGIT ROUTING TRANSIT NUMBER ___ ___ ___ ___ ___ ___ ___ ___ ___ <br />DEPOSITOR ACCOUNT TITLE <br />DEPOSITOR ACCOUNT NUMBER LOCKBOX NUMBER <br />TYPE OF ACCOUNT CHECKING SAVINGS LOCKBOX <br />SECTION IV SOCIO-ECONOMIC INFORMATION <br />Type of Business Large Business-No Socio-Economic Designations Minority SmBusiness Sm-Disadv/Minority Sm-Disadv Only SmMin Only <br />Sm-Disadvantaged Business Prog 8 (a) Firm HUBZone Program HUBZone Eligible Emerging Small Business Women-Owned Business <br />Other Preference Programs Buy Indian Directed to JWOD Non-Profit No Preference/Not Listed Small Business Set-Aside Very 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 (D) 251-500 (E) 501-750 (F) 751-1,000 (G) Over 1,000 (M) 1 million or less <br />(N) 1.1-2 million (P) 2.1-3.5 million (R) 3.1-5 million (S) 5.1-10 million (T)10.1-17 million (Z)Over 17 million <br />SECTION V CERTIFICATION OF DATA BY PAYEE/COMPANY <br />NAME TITLE/POSITION <br />SIGNATURE DATE TELE <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 United <br />States Government to provide a Tax Identification Number (TIN) and Electronic Funds Transfer (EFT) information for payment. PL 93-579 protects your privacy <br />and mandates that the information never be published or used for any other purpose than to pay you. Please complete all sections below, sign and return via the <br />email or fax number listed. <br />NAME AS SHOWN ON YOUR INCOME TAX RETURN <br /> EMAIL <br />RETURN FORM TO: <br />Exemptions (codes apply only to certain entities, not individuals): <br />Exempt payee code (if any) <br />Exemption from FATCA reporting code (if any) <br />(Applies to accounts maintained outside the U.S.) <br />U.S.) <br />S CorporationIndividual/Sole Proprietor or Single Member LLC <br />Limited Liability Company. Check the tax classification: C corporation S corporation Partnership Note. For a single-member LLC that is disregarded, check the appropriate box for the tax classification of the single-member owner. <br />Government Entity. Check the tax classification: Federal State Local <br />Other <br />USHR v. 112017 ms <br />Clear FormClear Form Print Form only, no instructionsPrint Form only, no instructions <br />Save FormSave Form Print Form & InstructionsPrint Form & Instructions <br />vendorEFT@mail.house.govvendorEFT@mail.house.gov