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Get and Sign Form Withholding
Name
DBA (see instructions)
Address (apt./ste., room, PO box, or PMB no.)
City (If you have a foreign address, see instructions.)
Telephone
State
ZIP code
Part III Type of Income Subject to Withholding
Check one type only. I
A m Payment to Independent Contractor
C m Rents or Royalties
B m Trust Distributions
D m Distributions to Domestic Nonresident
Partners/Members/Beneficiaries/
I Date(s) of Service __________________________
S Corporation Shareholders
mm/dd/yyyy -...
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