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State Form 53788 2009-2023
Payable to the DBA name)
Remit Address (number and street, city, state, and ZIP code)
Purchase Order Address – Optional (number and street, city, state, and ZIP code)
Enter 9-digit Taxpayer Identification Number (TIN) of the legal name:
(SSN=Social Security Number, EIN=Employer Identification Number)
(Individual's SSN) __ __ __ - __ __ - __ __ __ __
or
EIN __ __ - __ __ __ __ __ __ __
Check legal entity type (A box must be checked in this section. Check only one box.)
□ Individual
□...
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