Fill and Sign the 2015 Pa Individual Income Tax Declaration for Electronic Filing Pa 8453 Formspublications

RETURN TO: by mail to the agency who requested the form or sent it to you, or the agency you're doing business with. State of Maine Substitute W-9 & Vendor Authorization Form PURPOSE: To establish or update an account with the State of Maine's accounting system. Complete this form if: 1) You will receive payment from the State of Maine, and/or 2) You are a vendor who provides services or goods to the State of Maine. This form replaces the IRS W-9 form per the IRS W-9 language; "If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9." All items with an asterisk ( * ) must be completed. TYPE OF REQUEST*: (Must select one.) New New Location/Additional Request Entry Legal Name Change (Choose) Payment Address (ie.. DHHS/Labor/ DEP/Education/etc) DBA Name Contact Info Ordering Address TAXPAYER ID NUMBER* (TIN) (Provide ONE only) Social Security Number (SSN) Organization Type * Individual choose ONE Classification * Sole Proprietorship Individual choose ONE OR OR Federal Employer ID Number (FEIN) Company Foreign (W8 required) Corporation Trust Nonresident Alien State Gov't Partnership Other Gov't Other LEGAL NAME (Must provide: Legal name filed with IRS tied to the ID number, SSN=first & last name/FEIN=business name) Alias/DBA Legal Name* Other Info Vendor Customer Number (if known) VC#/VS# Payment Address* Account/Client/Provider Number (if known) Billing Address My Address Admin. Address is the same. C/O Phone City/State/Zip Contact* Name Phone Send me Email notifications of DD/EFT Email (requires Direct Deposit/EFT form to be completed) Procurement/Physical Address* Address City/State/Zip Ext Billing Address My Admin. Address is the same. C/O Phone Contact* Name Phone Ext Email Authorized Signature, Title & Current Date* Under penalties of perjury, I certify that: 1) The number shown on this form is my correct taxpayer identification number, and 2)I am not subject to backup withholding because: (a) I am exempt from backup witholding, or (b) I have not been notified by the 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. citizen or other U. S. person (defined by the IRS). Ref: www.irs.gov OFFICE USE ONLY State Agency & SHS # Information on State Agency Submitting Vendor Form Agency Contact Person Name & Title OFFICE USE ONLY Contact's Phone # ME W9 V3 05/03/12