Dear Vendor,

Thank you for your interest in the requirements of the U.S. Government Publishing Office.

Enclosed are IRS	Forms and W-9, the	Bidder’s Solicitation Mailing List Application, and a	

listing	of	our	Qualified	Products.	These forms should be completed in	their	entirety	and

returned to the address listed below.

If	you	are	interested in	any	of	the	items	listed	on	the	Qualified	Product	List,	please	specify

the product	code number	that	you are interested in and the specifications and sample

requirements will be sent to	you. You	can	also	view these requirements in	a pdf format

linked	to	the	product number in this file. The Mailing List Application should be sent to:

U.S. GOVERNMENT PUBLISHING	OFFICE

ACQUISITON SERVICES

732	North Capitol Street, N.W.

Room A529/A530 – Mail Stop: AS

Washington, DC 20401

Should you require	additional information, please	contact	Trena	Keys	on	202.512.0702.

I	can	be	reached	at	202.512.0351. Your interest in our requirements is appreciated.

Sincerely,

LORNA BAPTISTE-JONES

Chief, Acquisition	Services

U.S. GOVERNMENT PUBLISHING OFFICE | Keeping America Informed | OFFICIAL | DIGITAL | SECURE 

732 North Capitol Street, NW, Washington, DC 20401-0001 http://www.gpo.gov | www.facebook.com/USGPO | twitter.com/USGPO 
 

Commodity Bidders List

Check off only those items for which you are a regular dealer or manufacturer. 

Return this list along with the completed Standard Form 129 to: 

U.S. GOVERNMENT PUBLISHING OFFICE — ACQUISITION SERVICES 

732 North Capitol Street, NW, Room A332 – Mail Stop: AS, Washington, DC 20401 

QUALIFIED PRODUCT LIST 

The items listed below are qualifed products. click on the product number to review a pdf of product specifcations. 

We will send you specifcations and sample requirements if you wish to be considered for any of these bids list, 

please indicate Bid Number in block 10 of Form sF-129. 

0017 Adhesive, hot melt, P#024481 

0020 Adhesive, UV activated, P#291269 

0035 Adhesive, for Sheridan, P#186066 

0040 Adhesive, for Smyth, P#261246 

0055 Adhesive, passport, P#147664 

0070 Aluminum, roll leaf, P#031895 

0100 Blankets, 3-ply compressible, P#078727 

0110 Blankets, 4-ply compressible with bars, P#211401 & 

P#215759 

0120 Blankets, 3-ply conventional P#230685, P#230693 

0125 Blankets, 4-ply conventional P#209490, etc. 

0200 Chemical, dust control, Dust 

0255 Cleaner, toilet bowl, P#049964 

0260 Cleaner, glass P#204145 

0265 Cleaner, medicated skin, P#052400 

0270 Cleaner, general purpose P#191311 

0280 Defoamer, P#259926 

0300 Detergent, heavy duty, liquid P#219738 

0315 Developer, platemaker, P#220396 

0318 Disinfectant, Detergent, P#265489 

0376 Film, shrink wrap, P#252999 (pp) 

0380 Film, stretch wrap P#201561 & P#201626 

0382 Film, Misc. Graphic work, P#257982 

0384 Film, 70 mm for Rachwal Paginator Camera, P#241385 

0385 Film, 16 mm - 16MMMISC, P#240494, P#257982 

0401 Fabric, Coated for PP, P#291439, P#294551 

0406 Floor, stripper, “wet look”, P#242845 

0408 Floor, fnisher, high speed P#175269 

0450 Gloves, vinyl coated, P#261173, P#261181 

0455 Gloves, cotton P#011223 

0460 Gloves, leather work, P#025020, P#051438, P#070955 

0465 Gloves, liquid proof, neoprene coated, P#224995, 

P#225045, P#224987 

0475 Glue for Documents Pueblo, N/S Glue 

0500 Ink, heatset black, (local trade area only) P#257435 

0505 Ink, heatset, PMS - (local trade area only) PMS 

0540 Labels, die cut P#253201 

0550 Leaf, imitation gold, P#215732 

0555 Leaf, bronze, P#173525 

0590 Needles, Sewing, passport, P#253596 

0650 Packing material, plastic bubble, P#126365 

0655 Paint, Interior Acrylic Latex, P#285838 

0657 Paper Phototypesetting P#177580 

0661 Paper, typan, untreated, TYMPAN 

0665 Pens, ballpoint, P#266655 

0670 Phosphor, zinc ortho, P#112836 

0680 Plates, water washable, P#217271 

0685 Plates, pre-sensitized, long-run P#051012 

0686 Plates, pre-sensitized, coated P#243132, P#243141, 

P#243167 

0750 Solution, Fountain Etch P#044300 

0751 Solution, Fountain Etch, P#259276 

0755 Solvent, heatset, P#070327, P#118834 

0770 Spray, anti-skinning, P#137995 

0772 Spray, Insect, P#267601 

0775 Spray, silicone, P#178756 

0790 Strapping, polypropylene, P#233226 

0798 Tape, Banding, (P. Card), P#253472 

0799 Tape, Banding, P#252964 (PP) 

0800 Tape, carton, sealing P#252981 

0801 Tape, carton, sealing P#253715 

0804 Tape, cloth, P#253693, P#253685 

0817 Thread, 100% nylon, for passport, P#060151 

0818 Thread, Four card Cotton, Left Twist P#290025 

0845 Wax Blend, fourinated, P#652792 

0890 Wrap, biaxial shrink, P#253812 

Revised 9/2017
Give form to the 

requester. Do not 

send to the IRS. 

Form W-9 Request for Taxpayer 

Identification Number and Certification (Rev. October 2007) 

Department of the Treasury 

Internal Revenue Service 

Name (as shown on your income tax return) 

List account number(s) here (optional) 

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

City, state, and ZIP code 

Print or type

See Specific Instructions on page 2. 

Requester’s name and address (optional) 

Part I 

Business name, if different from above 

Check appropriate box: Individual/Sole proprietor Corporation Partnership 

Other (see instructions) © 

Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) © Exempt 

payee 

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 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 

Social security number 

your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or

Note. Employer identification number If the account is in more than one name, see the chart on page 4 for guidelines on whose 

number to enter. 

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 number to be issued to me), and 

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal 

Revenue Service (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 below). 

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup 

withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. 

For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement 

arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must 

provide your correct TIN. See the instructions on page 4. 

Sign Signature of 

Here U.S. person © Date ©

General Instructions 

Section references are to the Internal Revenue Code unless 

otherwise noted. 

Purpose of Form 

A person who is required to file an information return with the 

IRS must obtain your correct taxpayer identification number (TIN) 

to report, for example, income paid to you, real estate 

transactions, mortgage interest you paid, acquisition or 

abandonment of secured property, cancellation of debt, or 

contributions you made to an IRA. 

Use Form W-9 only if you are a U.S. person (including a 

resident alien), to provide your correct TIN to the person 

requesting it (the requester) and, when applicable, to: 

1. Certify that the TIN you are giving is correct (or you are 

waiting for a number to be issued), 

2. Certify that you are not subject to backup withholding, or 

3. Claim exemption from backup withholding if you are a U.S. 

exempt payee. If applicable, you are also certifying that as a 

U.S. person, your allocable share of any partnership income from 

a U.S. trade or business is not subject to the withholding tax on 

foreign partners’ share of effectively connected income. 

Note. 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. 

Definition of a U.S. person. For federal tax purposes, you are 

considered a U.S. person if you are: 

● An individual who is a U.S. citizen or U.S. resident alien, 

● A partnership, corporation, company, or association created or 

organized in the United States or under the laws of the United 

States, 

● An estate (other than a foreign estate), or 

● A domestic trust (as defined in Regulations section 

301.7701-7). 

Special rules for partnerships. Partnerships that conduct a 

trade or business in the United States are generally required to 

pay a withholding tax on any foreign partners’ share of income 

from such business. Further, in certain cases where a Form W-9 

has not been received, a partnership is required to presume that 

a partner is a foreign person, and pay the withholding tax. 

Therefore, if you are a U.S. person that is a partner in a 

partnership conducting a trade or business in the United States, 

provide Form W-9 to the partnership to establish your U.S. 

status and avoid withholding on your share of partnership 

income. 

The person who gives Form W-9 to the partnership for 

purposes of establishing its U.S. status and avoiding withholding 

on its allocable share of net income from the partnership 

conducting a trade or business in the United States is in the 

following cases: 

● The U.S. owner of a disregarded entity and not the entity, 

Cat. No. 10231X Form W-9 (Rev. 10-2007) 
Form W-9 (Rev. 10-2007) Page 2 

● The U.S. grantor or other owner of a grantor trust and not the 

trust, and 

● The U.S. trust (other than a grantor trust) and not the 

beneficiaries of the trust. 

Foreign person. If you are a foreign person, do not use Form 

W-9. Instead, use the appropriate Form W-8 (see Publication 

515, Withholding of Tax on Nonresident Aliens and Foreign 

Entities). 

Nonresident alien who becomes a resident alien. Generally, 

only a nonresident alien individual may use the terms of a tax 

treaty to reduce or eliminate U.S. tax on certain types of income. 

However, most tax treaties contain a provision known as a 

“saving clause.” Exceptions specified in the saving clause may 

permit an exemption from tax to continue for certain types of 

income even after the payee has otherwise become a U.S. 

resident alien for tax purposes. 

If you are a U.S. resident alien who is relying on an exception 

contained in the saving clause of a tax treaty to claim an 

exemption from U.S. tax on certain types of income, you must 

attach a statement to Form W-9 that specifies the following five 

items: 

1. The treaty country. Generally, this must be the same treaty 

under which you claimed exemption from tax as a nonresident 

alien. 

2. The treaty article addressing the income. 

3. The article number (or location) in the tax treaty that 

contains the saving clause and its exceptions. 

4. The type and amount of income that qualifies for the 

exemption from tax. 

5. Sufficient facts to justify the exemption from tax under the 

terms of the treaty article. 

Example. Article 20 of the U.S.-China income tax treaty allows 

an exemption from tax for scholarship income received by a 

Chinese student temporarily present in the United States. Under 

U.S. law, this student will become a resident alien for tax 

purposes if his or her stay in the United States exceeds 5 

calendar years. However, paragraph 2 of the first Protocol to the 

U.S.-China treaty (dated April 30, 1984) allows the provisions of 

Article 20 to continue to apply even after the Chinese student 

becomes a resident alien of the United States. A Chinese 

student who qualifies for this exception (under paragraph 2 of 

the first protocol) and is relying on this exception to claim an 

exemption from tax on his or her scholarship or fellowship 

income would attach to Form W-9 a statement that includes the 

information described above to support that exemption. 

If you are a nonresident alien or a foreign entity not subject to 

backup withholding, give the requester the appropriate 

completed Form W-8. 

What is backup withholding? Persons making certain payments 

to you must under certain conditions withhold and pay to the 

IRS 28% of such payments. This is called “backup withholding.” 

Payments that may be subject to backup withholding include 

interest, tax-exempt interest, dividends, broker and barter 

exchange transactions, rents, royalties, nonemployee pay, and 

certain payments from fishing boat operators. Real estate 

transactions are not subject to backup withholding. 

You will not be subject to backup withholding on payments 

you receive if you give the requester your correct TIN, make the 

proper certifications, and report all your taxable interest and 

dividends on your tax return. 

Payments you receive will be subject to backup 

withholding if: 

1. You do not furnish your TIN to the requester, 

2. You do not certify your TIN when required (see the Part II 

instructions on page 3 for details), 

3. The IRS tells the requester that you furnished an incorrect 

TIN, 

4. The IRS tells you that you are subject to backup 

withholding because you did not report all your interest and 

dividends on your tax return (for reportable interest and 

dividends only), or 

5. You do not certify to the requester that you are not subject 

to backup withholding under 4 above (for reportable interest and 

dividend accounts opened after 1983 only). 

Certain payees and payments are exempt from backup 

withholding. See the instructions below and the separate 

Instructions for the Requester of Form W-9. 

Also see Special rules for partnerships on page 1. 

Penalties 

Failure to furnish TIN. If you fail to furnish your correct TIN to a 

requester, you are subject to a penalty of $50 for each such 

failure unless your failure is due to reasonable cause and not to 

willful neglect. 

Civil penalty for false information with respect to 

withholding. If you make a false statement with no reasonable 

basis that results in no backup withholding, you are subject to a 

$500 penalty. 

Criminal penalty for falsifying information. Willfully falsifying 

certifications or affirmations may subject you to criminal 

penalties including fines and/or imprisonment. 

Misuse of TINs. If the requester discloses or uses TINs in 

violation of federal law, the requester may be subject to civil and 

criminal penalties. 

Specific Instructions 

Name 

If you are an individual, you must generally enter the name 

shown on your income tax return. However, if you have changed 

your last name, for instance, due to marriage without informing 

the Social Security Administration of the name change, enter 

your first name, the last name shown on your social security 

card, and your new last name. 

If the account is in joint names, list first, and then circle, the 

name of the person or entity whose number you entered in Part I 

of the form. 

Sole proprietor. Enter your individual name as shown on your 

income tax return on the “Name” line. You may enter your 

business, trade, or “doing business as (DBA)” name on the 

“Business name” line. 

Limited liability company (LLC). Check the “Limited liability 

company” box only and enter the appropriate code for the tax 

classification (“D” for disregarded entity, “C” for corporation, “P” 

for partnership) in the space provided. 

For a single-member LLC (including a foreign LLC with a 

domestic owner) that is disregarded as an entity separate from 

its owner under Regulations section 301.7701-3, enter the 

owner’s name on the “Name” line. Enter the LLC’s name on the 

“Business name” line. 

For an LLC classified as a partnership or a corporation, enter 

the LLC’s name on the “Name” line and any business, trade, or 

DBA name on the “Business name” line. 

Other entities. Enter your business name as shown on required 

federal tax documents on the “Name” line. This name should 

match the name shown on the charter or other legal document 

creating the entity. You may enter any business, trade, or DBA 

name on the “Business name” line. 

Note. You are requested to check the appropriate box for your 

status (individual/sole proprietor, corporation, etc.). 

Exempt Payee 

If you are exempt from backup withholding, enter your name as 

described above and check the appropriate box for your status, 

then check the “Exempt payee” box in the line following the 

business name, sign and date the form. 
Form W-9 (Rev. 10-2007) Page 3 

Generally, individuals (including sole proprietors) are not exempt 

from backup withholding. Corporations are exempt from backup 

withholding for certain payments, such as interest and dividends. 

Note. If you are exempt from backup withholding, you should 

still complete this form to avoid possible erroneous backup 

withholding. 

The following payees are exempt from backup withholding: 

1. An organization exempt from tax under section 501(a), any 

IRA, or a custodial account under section 403(b)(7) if the account 

satisfies the requirements of section 401(f)(2), 

2. The United States or any of its agencies or 

instrumentalities, 

3. A state, the District of Columbia, a possession of the United 

States, or any of their political subdivisions or instrumentalities, 

4. A foreign government or any of its political subdivisions, 

agencies, or instrumentalities, or 

5. An international organization or any of its agencies or 

instrumentalities. 

Other payees that may be exempt from backup withholding 

include: 

6. A corporation, 

7. A foreign central bank of issue, 

8. A dealer in securities or commodities required to register in 

the United States, the District of Columbia, or a possession of 

the United States, 

9. A futures commission merchant registered with the 

Commodity Futures Trading Commission, 

10. A real estate investment trust, 

11. An entity registered at all times during the tax year under 

the Investment Company Act of 1940, 

12. A common trust fund operated by a bank under section 

584(a), 

13. A financial institution, 

14. A middleman known in the investment community as a 

nominee or custodian, or 

15. A trust exempt from tax under section 664 or described in 

section 4947. 

The chart below shows types of payments that may be 

exempt from backup withholding. The chart applies to the 

exempt payees listed above, 1 through 15. 

IF the payment is for . . . THEN the payment is exempt 

for . . . 

Interest and dividend payments All exempt payees except 

for 9 

Broker transactions Exempt payees 1 through 13. 

Also, a person registered under 

the Investment Advisers Act of 

1940 who regularly acts as a 

broker 

Barter exchange transactions 

and patronage dividends 

Exempt payees 1 through 5 

Payments over $600 required 

to be reported and direct 1

sales over $5,000 

Generally, exempt payees 2 

1 through 7 

1

See Form 1099-MISC, Miscellaneous Income, and its instructions. 

2 

However, the following payments made to a corporation (including gross 

proceeds paid to an attorney under section 6045(f), even if the attorney is a 

corporation) and reportable on Form 1099-MISC are not exempt from 

backup withholding: medical and health care payments, attorneys’ fees, and 

payments for services paid by a federal executive agency. 

Part I. Taxpayer Identification 

Number (TIN) 

Enter your TIN in the appropriate box. If you are a resident 

alien and you do not have and are not eligible to get an SSN, 

your TIN is your IRS individual taxpayer identification number 

(ITIN). Enter it in the social security number box. If you do not 

have an ITIN, see How to get a TIN below. 

If you are a sole proprietor and you have an EIN, you may 

enter either your SSN or EIN. However, the IRS prefers that you 

use your SSN. 

If you are a single-member LLC that is disregarded as an 

entity separate from its owner (see Limited liability company 

(LLC) on page 2), enter the owner’s SSN (or EIN, if the owner 

has one). Do not enter the disregarded entity’s EIN. If the LLC is 

classified as a corporation or partnership, enter the entity’s EIN. 

Note. See the chart on page 4 for further clarification of name 

and TIN combinations. 

How to get a TIN. If you do not have a TIN, apply for one 

immediately. To apply for an SSN, get Form SS-5, Application 

for a Social Security Card, from your local Social Security 

Administration office or get this form online at www.ssa.gov. You 

may also get this form by calling 1-800-772-1213. Use Form 

W-7, Application for IRS Individual Taxpayer Identification 

Number, to apply for an ITIN, or Form SS-4, Application for 

Employer Identification Number, to apply for an EIN. You can 

apply for an EIN online by accessing the IRS website at 

www.irs.gov/businesses and clicking on Employer Identification 

Number (EIN) under Starting a Business. You can get Forms W-7 

and SS-4 from the IRS by visiting www.irs.gov or by calling 

1-800-TAX-FORM (1-800-829-3676). 

If you are asked to complete Form W-9 but do not have a TIN, 

write “Applied For” in the space for the TIN, sign and date the 

form, and give it to the requester. For interest and dividend 

payments, and certain payments made with respect to readily 

tradable instruments, generally you will have 60 days to get a 

TIN and give it to the requester before you are subject to backup 

withholding on payments. The 60-day rule does not apply to 

other types of payments. You will be subject to backup 

withholding on all such payments until you provide your TIN to 

the requester. 

Note. Entering “Applied For” means that you have already 

applied for a TIN or that you intend to apply for one soon. 

Caution: A disregarded domestic entity that has a foreign owner 

must use the appropriate Form W-8. 

Part II. Certification 

To establish to the withholding agent that you are a U.S. person, 

or resident alien, sign Form W-9. You may be requested to sign 

by the withholding agent even if items 1, 4, and 5 below indicate 

otherwise. 

For a joint account, only the person whose TIN is shown in 

Part I should sign (when required). Exempt payees, see Exempt 

Payee on page 2. 

Signature requirements. Complete the certification as indicated 

in 1 through 5 below. 

1. Interest, dividend, and barter exchange accounts 

opened before 1984 and broker accounts considered active 

during 1983. You must give your correct TIN, but you do not 

have to sign the certification. 

2. Interest, dividend, broker, and barter exchange 

accounts opened after 1983 and broker accounts considered 

inactive during 1983. You must sign the certification or backup 

withholding will apply. If you are subject to backup withholding 

and you are merely providing your correct TIN to the requester, 

you must cross out item 2 in the certification before signing the 

form. 
 

Form W-9 (Rev. 10-2007) Page 4 

3. Real estate transactions. You must sign the certification. 

You may cross out item 2 of the certification. 

4. Other payments. You must give your correct TIN, but you 

do not have to sign the certification unless you have been 

notified that you have previously given an incorrect TIN. “Other 

payments” include payments made in the course of the 

requester’s trade or business for rents, royalties, goods (other 

than bills for merchandise), medical and health care services 

(including payments to corporations), payments to a 

nonemployee for services, payments to certain fishing boat crew 

members and fishermen, and gross proceeds paid to attorneys 

(including payments to corporations). 

5. Mortgage interest paid by you, acquisition or 

abandonment of secured property, cancellation of debt, 

qualified tuition program payments (under section 529), IRA, 

Coverdell ESA, Archer MSA or HSA contributions or 

distributions, and pension distributions. You must give your 

correct TIN, but you do not have to sign the certification. 

What Name and Number To Give the Requester 

For this type of account: Give name and SSN of: 

1. Individual The individual 

2. Two or more individuals (joint The actual owner of the account or, 

account) if combined funds, the first 1

individual on the account 

3. Custodian account of a minor 2The minor 

(Uniform Gift to Minors Act) 

4. a. The usual revocable savings 1

The grantor-trustee 

trust (grantor is also trustee) 

b. So-called trust account that is 1

The actual owner 

not a legal or valid trust under 

state law 

5. Sole proprietorship or disregarded 3

The owner 

entity owned by an individual 

For this type of account: Give name and EIN of: 

6. Disregarded entity not owned by an 

individual 

7. A valid trust, estate, or pension trust 

8. Corporate or LLC electing 

corporate status on Form 8832 

9. Association, club, religious, 

charitable, educational, or other 

tax-exempt organization 

10. Partnership or multi-member LLC 

11. A broker or registered nominee 

12. Account with the Department of 

Agriculture in the name of a public 

entity (such as a state or local 

government, school district, or 

prison) that receives agricultural 

program payments 

The owner 

4

Legal entity 

The corporation 

The organization 

The partnership 

The broker or nominee 

The public entity 

Secure Your Tax Records from Identity Theft 

Identity theft occurs when someone uses your personal 

information such as your name, social security number (SSN), or 

other identifying information, without your permission, to commit 

fraud or other crimes. An identity thief may use your SSN to get 

a job or may file a tax return using your SSN to receive a refund. 

To reduce your risk: 

● Protect your SSN, 

● Ensure your employer is protecting your SSN, and 

● Be careful when choosing a tax preparer. 

Call the IRS at 1-800-829-1040 if you think your identity has 

been used inappropriately for tax purposes. 

Victims of identity theft who are experiencing economic harm 

or a system problem, or are seeking help in resolving tax 

problems that have not been resolved through normal channels, 

may be eligible for Taxpayer Advocate Service (TAS) assistance. 

You can reach TAS by calling the TAS toll-free case intake line 

at 1-877-777-4778 or TTY/TDD 1-800-829-4059. 

Protect yourself from suspicious emails or phishing 

schemes. Phishing is the creation and use of email and 

websites designed to mimic legitimate business emails and 

websites. The most common act is sending an email to a user 

falsely claiming to be an established legitimate enterprise in an 

attempt to scam the user into surrendering private information 

that will be used for identity theft. 

The IRS does not initiate contacts with taxpayers via emails. 

Also, the IRS does not request personal detailed information 

through email or ask taxpayers for the PIN numbers, passwords, 

or similar secret access information for their credit card, bank, or 

other financial accounts. 

If you receive an unsolicited email claiming to be from the IRS, 

forward this message to phishing@irs.gov. You may also report 

misuse of the IRS name, logo, or other IRS personal property to 

the Treasury Inspector General for Tax Administration at 

1-800-366-4484. You can forward suspicious emails to the 

Federal Trade Commission at: spam@uce.gov or contact them at 

www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338). 

Visit the IRS website at www.irs.gov to learn more about 

identity theft and how to reduce your risk. 

1

List first and circle the name of the person whose number you furnish. If only one person 

on a joint account has an SSN, that person’s number must be furnished. 

2 

Circle the minor’s name and furnish the minor’s SSN. 

3 

You must show your individual name and you may also enter your business or “DBA” 

name on the second name line. You may use either your SSN or EIN (if you have one), 

but the IRS encourages you to use your SSN. 

4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN 

of the personal representative or trustee unless the legal entity itself is not designated in 

the account title.) Also see Special rules for partnerships on page 1. 

Note. If no name is circled when more than one name is listed, 

the number will be considered to be that of the first name listed. 

Privacy Act Notice 

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, 

dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or 

contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. 

The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. 

possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal 

nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. 

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other 

payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.