SRPP - W9 Request Form

Request for Taxpayer Identification Number and Certification

Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service
Child Development Associates (CDA), has been contracted by the California Department of Social Services (CDSS) as part of the agreement between the State of California and Child Care Providers United (CCPU) codified as Senate Bill (SB) 140.

CDA will be issuing payments to Stage One and Bridge Program child care providers in support of those County Human Services Departments unable to issue the payments.

In order for CDA to process the payment, we must receive a valid W-9 Form for all eligible providers.

For more information regarding this payment program please visit: https://www.cdss.ca.gov/inforesources/child-care-and-development/subsidized-child-care-provider-stipends
Contact Information
Your Email Address*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Are you a license-exempt child care provider?*
Your Child Care Business License Number*
W-9 Form

Please reference the bottom of this form for a sample W-9 Form PDF available for download to review instructions and definitions.
1. First Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.*
Middle Name
Last Name*
2. Business name/disregarded entity name, if different from above
3. Check appropriate box for federal tax classification of the person whose name is entered on line. You may ONLY CHECK ONE of the following seven boxes*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/EstateLimited liability companyOther
3b. Limited liability company: Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)*
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Exemptions

Codes apply only to certain entities, not individuals. If needed, please reference the bottom of this form for a sample W-9 Form PDF available for download.
4a. Exempt payee code (if any)
4b. Exemption from FATCA reporting code (if any)
(Applies to accounts maintained outside the U.S)
Address

If needed, see instructions on sample pdf below.
5 and 6. Address (number, street, and apt. or suite no.) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. List account number(s) here (optional)
Requester’s Name (optional)

First NameLast Name
Requester's Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Part I - Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your Social Security Number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your Employer Identification Number (EIN) If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Which number will you be providing?*

Employer Identification Number (EIN)Social Security Number (SSN)
Enter your EIN*
A total of 9 digits.
Confirm your EIN*
A total of 9 digits.
Your EIN number must match.
Enter your SSN*
A total of 9 digits.
Confirm your SSN*
A total of 9 digits.
Your SSN number must match.
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 subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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 because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Signature*

Clear
Date*

MonthDayYear
Date
Sample W-9 for Instructions
Should be Empty:

Request for Taxpayer Identification Number and Certification

Contact Information

W-9 Form

Exemptions

Address

Part I - Taxpayer Identification Number (TIN)

Part II - Certification