Vendor Tax Information Form - Florida Polytechnic University
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1
2Florida Polytechnic University – Vendor Tax Information Form
Use this form ONLY if you are a U.S. person or entity (including U.S.
Collection and Use of Social Security Number
- The request for your SSN or
resident alien).
other Taxpayer Identification Number by University Disbursement Services is
mandated by 26 U.S.C. 6041 and related IRS regulations. If you have
questions about the collection and use of Social Security numbers at Florida
If you are a foreign person or entity, complete Form W-8BEN.
Poly, please contact us at 863-583-9050.
Part 1
– General Information:
Name
Taxpayer ID Number (SSN or EIN)
Business Name (DBA) ___________________________________________________________________________________________________________
Address
City
State
Zip
Expenditure Type:
For these expenditure types, skip Part 5 of this form.
Guest Speaker
Research Participant
Exam Proctor
Other: ___________________________________________
Part 2
- Tax Status:
Individual – If the vendor is a current Florida Polytechnic University employee, provide UFID, current job title and a brief description of their current job duties:
UFID: ___________________________________
Title: ____________________________________________________________________
Duties (describe or attach a copy of the current job description): ____________________________________________________________________
_______________________________________________________________________________________________________________________
Sole Proprietor (or an LLC with one owner) – The Taxpayer ID Number listed above must match the name given on the “Name” line to avoid backup withholding.
Partnership (or an LLC with multiple owners)
Corporation or tax exempt entity
Part 3
– Exemption: (If you are exempt from Form 1099 reporting, check your qualifying exemption reason below.)
Corporation
Tax Exempt Entity
The United States or
A state, the District of
A foreign government or
any of its agencies or
Columbia, a possession
any of its political subdivisions
Note that there is no
under 501(a) (includes
instrumentalities
of the United States, or
or an international
corporate exemption
501 (c) (3), or IRA)
any of their political
organization in which the
for medical and
subdivisions or agencies
United States participates
healthcare payments
under a treaty or Act of
or payments for legal
Congress
services
Part 4
– Minority Status:
Non-minority
Non-certified minority
Certified minority
Certified by:
African-American
Hispanic
Asian/Hawaiian
Native-American
Woman-owned
Non-certified
Certified
Certified by:
Part 5
– Employee/Independent Contractor Determination for services provided:
(Attach any supporting documentation to the form)
1.
Briefly describe the work/service to be provided: _______________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Are you a former Poly employee? ____No ____Yes
2.
If yes, will the proposed work/service be the same or similar to the work you performed
while an employee? ____No ____Yes
3.
Does the work/service involve teaching? ____No ____Yes (If yes, the course is ____ for credit
____ not for credit.)
4.
When will the work/service be performed (start/end dates, frequency, duration)? ______________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Where will the work/service be provided (from home, Poly-provided workspace/office, etc.)?_____________________________________________
5.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
What training, instruction, and supervision will be provided by Florida Poly regarding the proposed work/service? (Please describe.)
6.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
FA-UDS-VTIF 9/2012 Rev 12/2013
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