Form W-9 Payer’s Request for Taxpayer Local 66
Identification Number and Certification Fund Office
Name as shown on account
Address
City, State and ZIP code
Taxpayer Identification Number
Enter your taxpayer identification number in Social Security Number
the appropriate box. For most individuals, this
is your social security number. -- --
CERTIFICATION--Under penalties of perjury, I certify that:
The number shown on this form is my correct Taxpayer Identification Number.
Please Sign Here:
Signature Date
INSTRUCTIONS
Purpose of Form - Use this form to report and certify your identification number (TIN) to the payer.
Name - Be sure to enter your correct full name. -- ( First name, Middle initial & Last name)
If you are an individual and your name has changed, for example, because of marriage, contact
the Social Security Administration to report your new name. Also you must file a new Form W-9 with the
payer (Fund Office).
You are required to furnish your correct TIN ( your Social Security Number), and are Required to Sign the
certification.
WHAT NUMBER TO GIVE THE PAYER:
For this Type of Account: | Give the Social Security Number of:
1. Individual or Estate | Husband and wife must use their own number
PENALTIES - that may be imposed by the Internal Revenue Service.
Failure to Furnish TIN - If you fail to furnish your correct TIN to a payer, you are subject to a penalty of
$50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.
Criminal Penalty for Falsifying Information - Willfully falsifying certifications or affirmations may subject
you to criminal penalties including fines and/or imprisonment.
COMPLETE AND RETURN THIS FORM TO OPERATING ENGINEERS LOCAL 66 FUND OFFICE
P.O. BOX 38682, PITTSBURGH, PA 15238
