STATE OF CONNECTICUT- IMPORTANT: ALL parts of this form ... STATE OF CONNECTICUT-UNIVERSITY OF CONNECTICUT

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  • STATE OF CONNECTICUT-UNIVERSITY OF CONNECTICUT IMPORTANT: ALL parts of this form must be completed, signed and returned with

    completed W-9 to the UConn requesting department by the vendor.

    COMPLETE VENDOR LEGAL BUSINESS/INDIVIDUAL NAME Taxpayer ID # (TIN): SSN FEIN

    SSN/FEIN not Required for Reimbursements/Refunds

    BUSINESS NAME, TRADE NAME, DOING BUSINESS AS (IF DIFFERENT FROM ABOVE)

    BUSINESS ENTITY: CORPORATION LLC CORPORATION LLC PARTNERSHIP LLC SING NON-PROFIT PARTNERSHIP INDIVIDUAL/SOLE PROPRIETOR

    NOTE: IF INDIVIDUAL/SOLE PROPRIETOR, INDIVIDUAL’S NAME (AS OWNER) MUST APPEAR IN THE LEGAL BUSINES

    SALE OF COMMODITIES ATTORNEY FEES

    ENTERTAINMENT/PUBLIC SPEAKER MEDICAL SERVICES

    RENTAL OF PROPERTY (REAL ESTATE &

    UNDER THIS TIN, WHAT ARE THE TYPES OF BUSINESS YOU WILL PROVIDE TO THE UNIVERSITY:

    NOTE: IF YOUR BUSINESS IS A PARTNERSHIP, YOU MUST SUBMIT THE NAMES AND TITLES OF ALL PARTNERS WITH NOTE: IF YOUR BUSINESS IS A CORPORATION, IN WHICH STATE ARE YOU INCORPORATED? VENDOR ADDRESS STREET CITY STA

    VENDOR E-MAIL ADDRESS (REQUIRED) VENDOR WEB SITE

    REMITTANCE INFORMATION: INDICATE BELOW THE REMITTANCE ADDRESS OF YOUR BUSINESS. SAME AS VENDO REMIT ADDRESS STREET CITY STA

    COMPANY/INDIVIDUAL CONTACT INFORMATION: NAME AND TITLE (TYPE OR PRINT)

    1ST BUSINESS PHONE: Ext. # HOME PHONE: 2ND BUSINESS PHONE: Ext. #� CELLULAR: 1ST FAX NUMBER:�

    TOLL FREE PHONE:

    2ND FAX NUMBER:�

    WRITTEN SIGNATURE OF PERSON AUTHORIZED TO SIGN ON BEHALF OF THE ABOVE NAMED VENDOR

    SIGN HERE TYPE OR PRINT NAME OF AUTHORIZED PERSON TITLE OF AUTHORIZED PE

    IS YOUR BUSINESS CURRENTLY A CT DAS CERTIFIED SMALL BUSINESS ENTERPRISE (SMB) OR MINORITY BUSINESS ENTERPRISE (MBE)?

    YES (ATTACH COPY OF CE

    ARE YOU A CURRENT/FORMER STATE of CT EMPLOYEE

    PURCHASE ORDER DISTRIBUTION: (FAX NUMBER REQUIRED) NOTE: THE FAX NUMBER INDICATED IMMEDIATELY ABOVE WILL BE USED TO FORWARD PURCHASE ORDERS TO

    ADD FURTHER BUSINESS ADDRESS, E-MAIL & CONTACT

    INFORMATION ON SEPARATE SHE

    G

    Read & Complete Carefully - UConn Department please fax forms to 860-486-5846

    Revised 05-2015

    ARE YOU A UCONN STUDENT? YES (PEOPLESOFT #) NO

    DEPARTMENT NAME:

    YES NO CURRENT IF YES, PLEASE SELECT ONE OF THE FOLLOWING: FORMER RETIRED

    ARE ANY OF YOUR IMMEDIATE FAMILY MEMBERS CURRENTLY A STATE of CT EMPLOYEE? YES NO

    ***PLEASE NOTE THAT IF YOU ARE A CURRENT/FORMER STATE OF CT EMPLOYEE YOU COULD BE LIMITED OR PROHI PROVIDING SERVICES TO THE UNIVERSITY. PLEASE CONTACT THE APPLICABLE AGENCY FOR FURTHER CLARIFICATI

    CITIZEN AND ENTITY STATUS

    OTHER:

    NOTE: FOREIGN ENTITIES OR INDIVIDUALS MAY BE SUBJECT TO NRA TAXATION, WHICH MAY REQUIRE IMMIGRATION DOCUMENTS AND ADDITIONAL TAX FORMS. PLEASE CONSULT YOUR TAX ADVISOR FOR FURTHER DIRECTION.

    NOTE: FOR NON-CT INDIVIDUALS/ENTITIES ONLY: IF YOUR BUSINESS TYPE INCLUDES ENTERTAINMENT/PUBLIC SPE MAY BE SUBJECT TO CT WITHHOLDING TAX. PLEASE REFER TO CT DRS POLICY STATEMENT 2011(2) FOR CLARIFICATIO

    DEPARTMENTAL EMAIL:

    LE MEMBER ENTITY

    S NAME BLOCK ABOVE.

    EQUIPMENT)

    THIS FORM.

    TE ZIP CODE

    R ADDRESS ABOVE. TE ZIP CODE

    DATE EXECUTED

    RSON

    RTIFICATE) NO

    YOUR BUSINESS.

    ET IF REQUIRED

    OVERNMENT

    BITED IN ON.

    AKING/ATHLETICS, YOU N.

    PacholskiJ Note None set by PacholskiJ

    PacholskiJ Note None set by PacholskiJ

    PacholskiJ Note MigrationNone set by PacholskiJ

    PacholskiJ Note MigrationNone set by PacholskiJ

    rmp06001 Typewritten Text

    rmp06001 Typewritten Text

    rmp06001 Typewritten Text

    rmp06001 Typewritten Text

    rmp06001 Typewritten Text

  • ACH – Direct Deposit Election Form Email questions or Completed form to: APDisbursements.edu

    UNIVERSITY OF CONNECTICUT Accounts Payable Department 3 Discovery Drive, Unit 6080

    Storrs, CT 06269-6080 Fax: (860) 486-5846

    Part 1 Employee / Vendor Information

    Employee / Vendor Name: Employee #:

    Address: FEIN/Last 4 digts of SSN:

    Tel. #

    City: State: Zip:

    Dept. Name: Dept. Contact: (if employee) (if employee)

    E-Mail Address for Notification of Payment Detail:

    (If e-mail address changes, notify A/P IMMEDIATELY)

    Part 2 Bank Information CHECKING ACCOUNT ONLY (Enclose a Required Voided Check or Banking Documentation for verification purposes.)

    Bank Name:

    Routing & Transit #: (ABA#):

    Account#:

    DO NOT Close, cancel, or change your existing bank account without notifying the Accounts Payable Department

    Part 3 Authorization

    I hereby authorize the University of Connecticut (hereinafter “University”) to electronically deposit any payments made through the University of Connecticut, Accounts Payable Department, to the bank account specified above. This authorization is to remain in full force and effect until the University has received written notification from me of its termination in such time and manner as to afford the University and the bank named above a reasonable opportunity to act upon it. In the event that the University notifies the bank that funds have been deposited to my account in error, I hereby authorize and direct the bank to return said funds to the University as soon as possible. In the event that for any reason, the bank is unable to return said funds to the University, I hereby authorize the University to recover those funds by any of the following methods: (1) deducting the amount of said funds from any future payments from the University until the amount of erroneous deposit has been recovered in full; (2) making written demand on me for return of said funds, in which case I hereby agree to personally return said funds in full to the University within two (2) weeks of receipt of such written demand; or (3) any combination of methods (1) and (2) above. I further agree that if such funds are not repaid to the University, I will be personally liable for all costs of collection, including reasonable attorneys’ fees incurred by the University in the collection of such funds, together with the maximum interest permitted by law.

    I have read, understand, and agree to the above statement.

    Signature: _______________________________________________________ Date: ______________________________________

    Part 4 For office use only

    Employee #: ______________________________ Database/Bank Setup: _________________________ Verified by: __________________

    ______________________________ Vendor File: _________________________________ Verified by: __________________

    Rev 11/2017

    (if employee)

    (if vendor)

    NEW CHANGE

    Account Change If changing accounts then

    please enter the last four digits of the old account below .

    dap09017 Typewritten Text

  • Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service

    Request for Taxpayer Identification Number and Certification

    Give Form to the requester. Do not send to the IRS.

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    2.

    1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

    2 Business name/disregarded entity name, if different from above

    3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

    Individual/sole proprietor or single-member LLC

    C Corporation S Corporation Partnership Trust/estate

    Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

    Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

    Other (see instructions)

    4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any)

    Exemption from FATCA reporting

    code (if any) (Applies to accounts maintained outside the U.S.)

    5 Address (number, street, and apt. or suite no.)

    6 City, state, and ZIP code

    Requester’s name and address (optional)

    7 List account number(s) here (optional)

    Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

    Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

    Social security number

    – –

    or Employer identification number

    Part II Certification Under penalties of perjury, I certify that:

    1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a numb