Date: ___________________

Company Name: __________________________________________________

Physical Address: _________________________________________________

Mailing Address: _________________________________________________

(If Different)

City: ________________ State: _____________ Zip Code: _______________

Telephone Number: ( )_________ Fax Number: ( )

Toll Free Number: _______________ Email: __________________________

FEID Number: _______________ Or Social Security #: _________________

Contact Person: _________________________________________________

Title: ________________________ Cell #: ___________________________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Return vendor application and completed W-9 to:

Gilchrist County Clerk of the Court

Finance Department

P.O. Box 37

Trenton, FL 32693-0037

Dear Vendor,

The information requested above is necessary to update our files or to add your name

to the County’s vendor list. You are a vital part of the operation of Gilchrist County and we

want to thank you for your support. The information on this form will allow us to pay you

for the goods and/or services we have received in a timely manner and give us the ability to

contact the necessary person in case there is a problem or question in processing.

If at any time you have questions, please do not hesitate to contact Todd Newton, Clerk of

the Court, Wesley Roberts, Finance Director, Sherree Pitzerell, Accounts Payable or Sarah

Eastman, Accounts Payable at (352) 463-3170 or fax (352) 463-4050. Our office hours are

8:00 am to 5:00 pm, Monday thru Friday.

Gilchrist County

Board of County Commissioners

Vendor Application

Expiration

GILCHRIST COUNTY BOARD OF COuNTYCOMMISSiONERSit2 S MAIN STTRENTON FL 32693-3200

0000028 01′ 10/12

Celtttate Number

This certifies that

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eヽxemptfrom the payment Of Flottda Sales and uSe tax On real pおpetty rented,tranSent rental''rop8ny‐ 誌lied,tanglble

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lrnportantinformation fOr Exempt Organizations

,.,', w-g(Rev. December2011)Departmenl ol the Treasurylntemal Reverue Sewic€

Request for Taxpayerldentification Number and Certification

Give Form to therequester. Do notsend to the lRS.

Exempt payee

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Business narne/disregarded entity name, if diflerenl from above

Ust accouni numbe(s) here (oplional)

instructions on page 4.

Here

Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line

to avoid backup withholding. For individuals, ihis is your social security number (SSN). However, lor aresident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3 For otherentities, it is your employer identification number (ElN). lf you do not have a number, see How to getaLN on page 3.

Not€. lf the account is in more than one name, see the chart on page 4lor guidelines on whose

number to enter.

Under penalties of periury, I certify thai:.l . The number shown on this form is my correct taxpayer identilication number (o{ I am waiting for a number to be issued to me), and

2. I am not subject to backup withhotding because: (a) I am exempt ,Iom backup withholding, or (b) I hav€ not been nolified by the lntemal Revenue-

serviie trnsilrat r u, "r6;"a

to u""x'rl ,riintr"tdiig "" "

,ouit ol a tailure to report all interest or dividends, or (c) the lRs 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 lRs that you are currently subject to backup withholding

#;;;t;;h;;;aibd to repoa at interesiinJdivioends on your tax retum- Flr real estate trarsactions, item 2 does not applv For mortgage

interest paid, acquisition or abanoon-enG;r-r; p-;p;,ly,';cellation of debt, contributions to an individual retirement anangement (lRA), and

g;"!iiiti,-r;fi,r],'t" "ttrer

ttran interest anJ a-Jii-ena-siyJu aii not requked to sign ihe certilication, but you must provide vour conect TlN See the

Requester's name and

Date l・Signalure otU.S. person >

General lnstructionsSection references are to the lntemal Revenue Code unless otherwisenoted.

Purpose of FormA oerson who is required to file an information return with the IRS must

obtain your conect iaxpayer identillcalion number OIN) to repori, forexamoie. income oaid to vou, real estate transactions, mortgage interestyou paid, acquisition or a6andonment of secured property, cancellation;f debt. or contributions vou made lo an lRA.

Use Form W-9 onty 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. Cedity that theTlN you are giving is corect (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 exemptoavee. lf aoDlicable, vou are also certifying lhat as a U.S person, your

it6cabte strare of ani partnership income from a U S trade or business

is not subiect to the withholding tax on foreign partners' share of

Note. lf a requester gives you a form other than Form W-9 to requestyourTlN, you must ule th; requester's form if it is substantially similarto this Form W-9.

Definltion of a U-S. p€rson. Forlederaltax purposes, you are

considered a U.S. Person if You are:

. An individual who is a U.S. cilizen or U-S. resident alien,

. A partnership, corporation, company, or association created ororganized in the United States or under the laws of the United States,

. An estate (other than a loreign estate), or

. A domestic trust (as defined in Regulations section 301-7701-O'

Special rules lor Partnerships. Partnerships thai conduct a hade or..

b;siness in the U;iied States are generally required to pay a withholdingtax on anv foreiqn partners' share of income from such business'Furttrer. iri certai-n cases where a Form W_9 has not been received, a

oartnershiD is requked 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

partneiin a partnership conducting a trade or business in the United

btates. orovlde Fo.m \fu-g to the partnership to establish your U S

status and avoid withholding on your share ol parinership income'

Check appropriale box for federal tax classilication:

E hdividuausote proprietor f] c corporalion E s co.po.atlon E parttersrrip fl Tnrsyestate

I Umitea faUtity company. Enter the tax classiricatioo (C=C corporation, S=S corForation, P=partnership) >

, street, and apt. or suile no-)

connected income.Cat No 10231X Fom W‐ 9(Rev 12 20111

Fom W・9(ReV∝tobor 2∞ ηOepa■ment oll卜8予 eaSじ″int“隧l Rever● e se,Ⅲ

Request for Taxpayeridentification Number and Certification

Glvo torm to thsrequgstor. Do notsond to the lRS.

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Nam6 (as 5hown on yolrr income tax r6lum)

Busin€ss name, if ditlerent frcm above

Lbt accolmt nurnb€(6) her6 loptlonal)

Entor your TIN ln ihe approprlate box. The TIN provlded must match lh6 name glveo on Une 1 io avoidbackup withholding. For indivlduals, thls ls your soclal security numb€r (SSN). However, tor a r€sldent8li€n, sole propdetor, or disregarded entity, s66 th€ Part I lnstruciions on pag€ 3. For othel Enlities, it lsyour employer ldentiflcatlon number (ElN). ll you do not have a number, see How lo gsl a 7N on pags 3.

Noto. lf ths account is In more lhan one nam6, see th6 chart on pago 4 lor guidelines on whosenumbEr lo entar.

Under psnaltles ol perjury, I cerlify that:

1. Th6 numbgr shown on this lorm is .Ey correct taxpaysI ldenUflcalion number (or I am walting tor a number to be l$ued to mo), and

2. I am not subject to backup wlthholding becauss: (a) I arn oxempt lrom backup withholdlng, or (b) I havs not be€n notilied by lhs lntornalRevenuo S€rvlco (lRS) that I am subjeat to bsckup withholding as a result of a lallure to report all lnt€rest or dlvidends, or (o) tho IHS hasnolltied me that I am no longsr subject to backup withholdlng, and

3. lam a U.S. cltizen or other U.S. porson (d€flned bolow).

O€rtlllcailon lffitructlons. You must cross out item 2 abovo if you havo been notified by the IBS that you are cur,efltly sub,ect to backupwithholding beoaus6 you haw l8ilod to report all lnterB3l and divld€nds on your tax retum. For roal ostate transactlons, itom 2 doss not apply,For mortgige Int€res{ pald, acquisition or abandonm€nt ol secured propedy, cancellation ol dEbt, contributions io an lndivldual rotlromontanangsr;o;l (tRA), and goneratly, psymonts other than lnlsrost and dlvldsnds, you aro not requlred lo slgn tho Cetllllcatlon, but you mustprovlde your conect TlN. S€e th6 lnsttuctlons on pago 4.

SignHere

GeneralSection relersncos are to lhe lntornal Bevenuo Codo unlessotherwiss noted.

Purpose of FormA porson who ls requlred to llls an lnformation return with lh€IRS must obtain your conect taxpayar ldentification numb€r OIN)to report, lor 6xample, income pald to you, leal estatetransbctions, mortgago lnt€rost you paid, acqulsition orabandonmgnt of secured propsrty, cancellation of debt, orcontrlbutions you mad6 to an lBA.

Use FoIm W-g only if you are a U.s. person (including arosldsnt alien), lo provids your conect TIN to the p€rsonrequssting it (tho requester) and, when appllcable, to:

1. Cerilty that the TIN you aro glvlng ls correct (or you arowalting lor a numb6r to be lssueo,

2. Certlly thai you are not subiect to backup wllhholding, or

3. Claim sxemption lrom backup withholdlng if you are a U.S.6x€mpt payee, lf appllcable, you aro slso certlfylng that as aU,S. oerson, your allocable sharo ol aoy parlnershlp lncome lroma U.S. trado 6r business ls not sublBct to the withholding tax onlor€lgn partn€rs' share ol affectivsly connect€d lncome.

Nolo. l[ a r€ousster oives you a lorm oiher than Form W-9 toreouest your TlN, yoi musi uso the requeste/s lorm It it lssu6stantjally slmilar to this Form W-9.

Daflnltlon ol a U.S. porson. Fo, tederal tax purposes, you areconsld€red a U,S. person it you aro:o An lndividualwho ls a U.S. citizen or U.S. rosldont alien,. A partnershlp, corporatlon, company, or assoclation created ororganlzed ln th6 Unltgd States or under the laws ol the UnitedStatos,. An esiat€ (other lhan a loreign aetate), or. A domesiic trust (as defined in Regulatlons soclion301.7701-4,Spoclal rules ,or parlnershlps. Partnershlps that conduct atrads or business In tho United Statos are gonerally requked topay a wlthholding tax on any lorelgn partnors' share of lncomsirom such buslness. Furlher, ln certain cases wharo a Form W'9has not bo€n received, a partnership is requlrod to prasumo thata partnor ls a foreign perion, and pay the withholding tax'Therefore, il you ar€ a U.S. pgrson that ls a partne, ln apartnershlp cbnductlng a trads or buslnass ln the Unlted Staiss,brovlde Fdrm W-9 to lho partnership to ostabllsh your u.S.status and avold withholding on your sharo of parlnershlplncom6.

The person who givos Form W-9 to the partnershlp for .

ourposes ol esiablishing its U.S. slatus and avolding withholdlngbn its allocable share of net income from ths parlnershlpconduotlng a lrads or busin8ss ln tho United States ls ln thsfollowlng cases:

. Th6 U.S. owner ot a dlsregarded antity and not lho €ntity,

日電鶉 ι‰ 風 IW‖踏 "prletOr□corpOm晰 □ Pannershlp

t●x cla弱Ocallon(Dttlsregaded eniity.c cOrpOdbn.p_pTh“ hipl● ____

Addregg (number, stre6l, anal 6pl. or suito noJ

Cily.state,and zlP code

591600

lRev 10‐ 200η