** NOTE: Payments will be held until a valid TIN is received **
Questions? Call (402) 544-2729
Name:  
(requested by)
 Business Name:   
(doing business as)
Phone Number:        Address:   
City:       State:        Zip:   
E-mail:   

Check ONE:         
Individual          Limited Liability Corporation
Partnership          Limited Liability Partnership
Federal/State/Local Government          Sole Proprietorship
Corporation          Not-For-Profit Organization
 
Are you currently subject to backup withholding?          Do you require a Form 1099 at year end?
Yes No          Yes No

Part I Bank Account Detail

Bank Routing Number
Bank Account Number

Part II Taxpayer Identification Number (TIN)
  Enter your TIN in the appropriate box.
** NOTE: Payments will be held until a valid TIN is received **

Taxpayer Identification Number (TIN)

Part III Certification
Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).

Signature:       
Contact Number:
Printed Name:
Date:

Part IV Voluntary Vendor Information

Company is more than 50% owned, controlled, or actively managed by a:
Women Owned
Veteran Owned
Minority Owned
Other
None of the above
If "Minority Owned" please check ONE of the following:
African American        Asian Pacific American
Hispanic American      Other
Native American
Asian American
Asian Indian American
Certification Agency Certification Number Expiration Date
*Certification agencies act on behalf of the government to ensure that a business is actually owned/managed by a minority.

    

On submission this form gets faxed to the Accounting Department at Union Pacific