** NOTE: Payments will be held until a valid TIN is received **
Questions? Call (402) 544-2729
    Name:
(as shown on your income tax return)
    Business Name:
(if different from above; DBA)
    Phone Number:
    Remittance Address:
    City:       State:        Zip:   
    Remittance E-mail:

Select appropriate choice for federal tax classification (required):
Individual/sole proprietor   Trust/estate
C Corporation   Limited Liability Company
S Corporation   Other
Partnership    
 
Are you currently subject to backup withholding?          Do you require a Form 1099 at year end?
Yes No          Yes No

Part I Taxpayer Identification Number (TIN)
  Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). The   TIN provided must match the name as shown on your income tax return.
** NOTE: Payments will be held until a valid TIN is received **

Employer Identification Number (EIN) Social Security Number (SSN)
-- ----

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 to backup withholding, and
  3. I am a U.S. citizen or other U.S. person
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 becasue you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. Generally, for payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN

Signature:       
Telephone Number:
Printed Name:
Date:

Part III Bank Account Details ( Required in order to receive payment via ACH)

Bank Routing Number
Bank Account Number
Second Contact (from within your organization)
Telephone Number
 

If a second contact cannot be provided, please fax a copy of a voided check to (402) 233-3394

Part IV Other 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