Fax & completed W-9 formGary Sieb - w-9
Page 1 of I
From: "DAVID FRANKS" <dlfranksl0(~msn.com>
TO: <gsieb@ci.coppell.tx.us>
Date: 7/9/2004 8:55 AM
Subject: w-9
CC: <mason.griffin@bracepatt.com>
Gary, per our conversation this morning, please fax the completed W-9 to me at the below fax and mail the hard copy to the below address.
Thanks,
David Franks
Site Acquisition Services, Inc.
1418 Travis Cimle North
Irving, TX 75038
Ph: 214-766-9123
Fax: 972-255-3800
file://D:\Temp\GW } 00001 .HTM 7/9/2004
wireless
SUBSTITUTE W-9 AND VENDOR CLASSIFICATION FORM
Check all boxes in the following sections that apply to your business
(Incomplete forms will cause Delays on Payments)
City of Coppell
255 Parkway Boulevard
Coppell, TX 75019
IS THIS COMPANY MINORITY, WOMAN OR PROTECTED CLASS-OWNED
- If this address is incorrect, please change.
~ If you have had a name change, please
include written documentation and new
federal tax identification number.
MIW/DV BE)? [] YES [~ NO If yes, please select from below
GENDER: [] Male [] Female BUSINESS OWNERSHIP/CLASSIFICATION: [] African Arner~-.an [] As~an/PaciflcAmerican
[]As~an/Subconflnent Amen(an F-~HispanicAmedcan Nativ~lndian/Es~rno/HawaiianAmedcanr~Non-minority []Personsw#hDisability
[] Service Disabled Veteran [] Viefmam-era Veteran Veteran
BUSINESS TYPE: [] Large [] Small [] 8(A) SDB [] Small Disadvantaged Business [] HUB
CERTIFYING AGENCY: CalifomiaC~earinghouse (CPUC) NMSDC(Affiliate) Stere SBA WBENC USPAACC
Other (sp~ify)
if certified, please fax or rnail a copy of this form a nd your certification form to: Gwen Wilson, Vedzon Wireless, bOO Hidden Ridge, MC# HQ£04D12, irving,
TX 75118 (fax#972-718~337) For more informaflon, Jog on to the v~bs;te at www verizonwireless.corn/supplierdivem~ty
BUSINESS ACTIVITY: (Check One)
Consultant ! Professional Fees
CHECK IF APPLICABLE:
A Division of
(Same Federal Tax ID as Parent)
A Wholly~vned Sub.diary of
(Different Federal Tax ID than ParapetI
Non-US Supplier
(Primarily of Foreign Origin)
(Parent Compa*lyI [Parent Company) (Country)
PAYMENTTERMS: ~9.~ ~ mnnth ~th escalator
Use this form only if you are a U S person (including U S readem allen) If you am a foreign person, use the appropriate Form
Instructions - for following page
1 Complete Par~ 1 by completing the one row of boxes that corresponds to your tax status.
2 Complete Par~ 2 if you are exempt from Form 1099 repor~ng
3. Complete PaR 3 to sign and date the form
4 Return this completed form to us in the enclosed envelepe (No~e: IfyouareaMNV/DVBEpleasefaxormailacopyofthis
form and your certification form as instructed abow )
Part 1 - Tax Status: (complete only one row of boxes)
Individuals:
(Fill out this row) Individual Name: (First name, middle initial last name)
Sole Proprietor:
(Fill out fl3is mw)
Partnership:
(Fill out this row)
Business Owner's Name: (REQUIRED) Bus~ness Owner's Social Security Number Business or Trade Name
(OPTIONAL)
(First name) (Middle initial)
er Employer ID Number
(Last name)
(Fillout~is~) _ City 0;[ Coppell names(OBAs)
l~5_-I I 8 3 2 0 7 Y~ No
AND rde lit I
Part 2- Exemption: Ifexemptf~omFormlO99repo~ng, checkhere: cl ~urqua y~ngexemp~onreasonDe~w:
1 Corporation 2 Tax Exempt 3 The United States
except there is Chary under or any of its agercies
r~ exempher) for 501 (a) (includes or instrumentalities
medical and 501 (a)(3), or IRA)
healthcare
Part 3 - Signature: I am a U S person (including a US resident alien)
Person completing this form: l'{m Mitt-
Title: ~ Name: ' '
Signature---" ---~-~ '~ Date: 7/.--~/. /~' ~
(this ~"-./'- ' -
information
Tax correspondence address ~'inance Oepartmel3.t
255 Parkway Boulevard
City: ~..a;;t.O~..~ State: ~ ZIP: 75019
~hone: (9~2_) 30/, ~'{691
5 A foreign government
or any of its political
s~bdiviaons
Nonresident aliens:
US. reskJent aliens who claim a treaty benefit based
on a saving clause must complete a form W-9
form is acceptable) and attach the required
to avoid backup withholding. (treaty country, treaty ar[icle
addressing the income, the article number in the tax treaty
that contains the saving clause and i~ exceptions, the
type and amount of income that qualifies for the exemption
from tax, and sufficient facts to justify the exemption
from tax under the terms of the treaty article)
If address for payment is different, please list payment remit address below:
Remit address:
City: State: ZIP: