CARRIER PROFILE FORM
Equipment Information (Approximate Number)
Carrier Reference List
Please provide atleast 5 references of the brokers you have worked in the past 60-90 days.
| Company Name | Point of Contact | Phone # |
|---|---|---|
Employee’s Withholding Certificate
|
Form W-9 |
Request for Taxpayer Identification Number and Certification▶ Go to www.irs.gov/FormW9 for instructions and the latest information |
Give Form to the requester. Do not send to the IRS. |
Print or type. See Specific Instructions on page 3 |
1. Name (as shown on your income tax return). Name is required on this line; do not leave this line blank |
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2. Business name/disregarded entity name, if different from above |
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3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. |
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4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): |
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Exemption from FATCA reporting code (if any) |
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Requester’s name and address (optional) |
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5. Address (number, street, and apt. or suite no.) See instructions |
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6. City or town, state, and ZIP code |
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7. List account number(s) here (optional) |
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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.
.
Social security number
or
Employer identification number
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.
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Date ▶ |
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General Instructions
Section references are to the Internal Revenue Code unless
otherwise
noted.
Future developments. For the latest
information about developments
related to Form W-9 and its instructions, such as
legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required
to file an
information return with the IRS must obtain your correct
taxpayer
identification number (TIN) which may be your social
security number
(SSN), individual taxpayer identification number (ITIN),
adoption
taxpayer identification number (ATIN), or employer
identification number
(EIN), to report on an information return the amount paid to
you, or other
amount reportable on an information return. Examples of
information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or
mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards,
or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network
transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan
interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured
property)
Use Form W-9 only if you are a U.S. person (including a
resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN,
you might
be subject to backup withholding. See What is backup
withholding,
later.
Form W-9 (Rev. 10-2018) Page 2
1. Certify that the TIN you are giving is correct (or
you are waiting for a number to be issued),
2. Certify that you are not subject to backup
withholding, or
3. Claim exemption from backup withholding if you are a
U.S. exempt payee. If applicable, you are also
certifying that as a U.S. person, your allocable share
of any partnership income from a U.S. trade or
business is not subject to the withholding tax on
foreign partners' share of effectively connected
income,
and
4. Certify that FATCA code(s) entered on this form (if
any) indicating that you are exempt from the
FATCA
reporting, is correct. See What is FATCA reporting,
later, for further information.
Note: If you are a U.S. person and a requester
gives you a form other than Form W-9 to request
your TIN,
you must use the requester’s form if it is substantially
similar to this Form W-9.
Definition of a U.S. person. For federal tax
purposes, you are considered a U.S. person if you
are:
• An individual who is a U.S. citizen or U.S. resident
alien;
• A partnership, corporation, company, or association
created or organized in the United States or under
the laws of the United States;
• An estate (other than a foreign estate); or
• A domestic trust (as defined in Regulations section
301.7701-7).
Special rules for partnerships. Partnerships that
conduct a trade or business in the United
States are
generally required to pay a withholding tax under
section 1446 on any foreign partners’ share of
effectively connected taxable income from such business.
Further, in certain cases where a Form W-9 has
not been received, the rules under section 1446 require
a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding
tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business
in the United States, provide Form W-9 to the
partnership to establish your U.S. status and avoid
section 1446 withholding on your share of
partnership income.
In the cases below, the following person must give Form
W-9 to the partnership for purposes of
establishing its U.S. status and avoiding withholding on
its allocable share of net income from the
partnership conducting a trade or business in the United
States.
• In the case of a disregarded entity with a U.S. owner,
the U.S. owner of the disregarded entity and
not the entity;
• In the case of a grantor trust with a U.S. grantor or
other U.S. owner, generally, the U.S. grantor or
other U.S. owner of the grantor trust and not the trust;
and
• In the case of a U.S. trust (other than a grantor
trust), the U.S. trust (other than a grantor trust)
and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or
the U.S. branch of a foreign bank that has elected
to be
treated as a U.S. person, do not use Form W-9. Instead,
use the appropriate Form W-8 or Form 8233 (see
Pub. 515, Withholding of Tax on Nonresident Aliens and
Foreign Entities).
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual
may use
the terms of a tax treaty to reduce or eliminate U.S.
tax on certain types of income. However, most tax
treaties contain a provision known as a “saving clause.”
Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain
types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax
treaty to claim an exemption from U.S. tax on certain
types of income, you must attach a statement to
Form W-9 that specifies the following five items.
1. The treaty country. Generally, this must be the same
treaty under which you claimed exemption from
tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty
that contains the saving clause and its
exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax
under the terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making
certain payments to you must under certain conditions
withhold and pay to the IRS 24% of such payments. This
is called “backup withholding.” Payments that may
be subject to backup withholding include interest,
tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee
pay, payments made in settlement of payment card
and third party network transactions, and certain
payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on
payments you receive if you give the requester
your
correct TIN, make the proper certifications, and report
all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the
instructions for
Part II for details),
3. The IRS tells the requester that you furnished an
incorrect TIN,
4. The IRS tells you that you are subject to backup
withholding because you did not report all your
interest and dividends on your tax return (for
reportable interest and dividends only), or
5. You do not certify to the requester that you are not
subject to backup withholding under 4 above (for
reportable interest and dividend accounts opened after
1983 only).
Certain payees and payments are exempt from backup
withholding. See Exempt payee code, later, and the
separate Instructions for the Requester of Form W-9 for
more information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to
furnish your correct TIN to a requester, 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.
Civil penalty for false information with respect
to withholding. If you make a false
statement with no
reasonable basis that results in no backup withholding,
you are subject to a $500 penalty.
Form W-9 (Rev. 10-2018) Page 3
Criminal penalty for falsifying information.
Willfully falsifying certifications or affirmations
may
subject you to criminal penalties including fines and/or
imprisonment.
Misuse of TINs. If the requester discloses or
uses TINs in violation of federal law, the
requester may
be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do
not
leave this line blank. The name should match
the name on your tax return.
If this Form W-9 is for a joint account (other than
an
account maintained by a foreign financial
institution (FFI)), list first, and then circle, the
name of the person or entity whose number you
entered in Part I of Form W-9. If you are providing
Form
W-9 to an FFI to document a joint account, each
holder of the account that is a U.S. person must
provide
a Form W-9.
a. Individual. Generally, enter the name
shown on
your tax return. If you have changed your last
name
without informing the Social Security Administration
(SSA) of the name change, enter your first name,
the last name as shown on your social security card,
and
your new last name.
Note: ITIN applicant: Enter your individual
name
as it was entered on your Form W-7 application,
line
1a. This should also be the same as the name you
entered
on the Form 1040/1040A/1040EZ you filed with
your application.
b. Sole proprietor or single-member LLC.
Enter
your individual name as shown on your
1040/1040A/1040EZ
on line 1. You may enter your business, trade, or
“doing
business as” (DBA) name on line 2.
c. Partnership, LLC that is not a single-member
LLC,
C corporation, or S corporation. Enter the
entity's
name as shown on the entity's tax return on line 1
and
any business, trade, or DBA name on line 2.
d. Other entities. Enter your name as shown
on
required U.S. federal tax documents on line 1.
This name
should match the name shown on the charter or other
legal document creating the entity. You may enter
any business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax
purposes, an entity that is disregarded as an entity
separate from its owner is treated as a “disregarded
entity.” See Regulations section
301.7701-2(c)(2)(iii). Enter the owner's name on
line 1.
The name of the entity entered on line 1 should
never be a disregarded entity. The name on line 1
should
be the name shown on the income tax return on
which the income should be reported. For example, if
a
foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single
owner
that is a U.S. person, the U.S. owner's name is
required to be provided on line 1. If the direct
owner
of the entity is also a disregarded entity, enter
the first owner that is not disregarded for federal
tax
purposes. Enter the disregarded entity's name on
line 2, “Business name/disregarded entity name.” If
the
owner of the disregarded entity is a foreign
person, the owner must complete an appropriate Form
W-8
instead of a Form W-9. This is the case even if
the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name,
or
disregarded entity name, you may enter it on line
2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.
| IF the entity/person on line 1 is a(n) . . . | THEN check the box for . . . |
|---|---|
| • Corporation | Corporation |
| • Individual • Sole proprietorship, or • Single-member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes. |
Individual/sole proprietor or single- member LLC |
| • LLC treated as a partnership for U.S. federal
tax purposes, • LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or • LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S. federal tax purposes. |
Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= S corporation) |
| • Partnership | Partnership |
| • Trust/estate | Trust/estate |
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA
reporting, enter in the appropriate space on line
4 any code(s) that may apply to you.
Exempt payee code.
• Generally, individuals (including sole proprietors)
are not exempt from backup withholding.
• Except as provided below, corporations are exempt from
backup withholding for certain payments,
including interest and dividends.
• Corporations are not exempt from backup withholding
for payments made in settlement of payment card or
third party network transactions.
• Corporations are not exempt from backup withholding
with respect to attorneys’ fees or gross proceeds
paid to attorneys, and corporations that provide medical
or health care services are not exempt with
respect to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from
backup withholding. Enter the appropriate code
in the space in line 4.
1—An organization exempt from tax under section 501(a),
any IRA, or a custodial account under section
403(b)(7) if the account satisfies the requirements of
section 401(f)(2)
2—The United States or any of its agencies or
instrumentalities
3—A state, the District of Columbia, a U.S. commonwealth
or possession, or any of their political
subdivisions or instrumentalities
4—A foreign government or any of its political
subdivisions, agencies, or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to
register in the United States, the District of
Columbia, or a U.S. commonwealth or possession
7—A futures commission merchant registered with the
Commodity Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year
under the Investment Company Act of 1940
10—A common trust fund operated by a bank under section
584(a)
11—A financial institution
12—A middleman known in the investment community as a
nominee or custodian
13—A trust exempt from tax under section 664 or
described in section 4947
Form W-9 (Rev. 10-2018) Page 4
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
| IF the payment is for | THEN the payment is exempt for |
|---|---|
| Interest and dividend payments | All exempt payees except for 7 |
| Broker transactions | Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. |
| Barter exchange transactions and patronage dividends | Exempt payees 1 through 4 |
| Payments over $600 required to be reported and direct sales over $5,0001 | Generally, exempt payees 1 through 5 |
| Payments made in settlement of payment card or third party network transactions | Exempt payees 1 through 4 |
See Form 1099-MISC, Miscellaneous Income, and its instructions.
However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.
A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I—A common trust fund as defined in section 584(a)
J—A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section 4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g) plan
Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
your TIN in the appropriate box. you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.
If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.
Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days.If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.
Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier.
Signature requirements. Complete the certification as indicated in items 1 through 5 below.
Form W-9 (Rev. 10-2018) Page 5
1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
| For this type of account: | Give name and SSN of: |
|---|---|
| 1. Individual | The individual |
| 2. Two or more individuals (joint account) other than an account maintained by an FFI | The actual owner of the account or, if combined funds, the first individual on the account |
| 3. Two or more U.S. persons (joint account maintained by an FFI) | Each holder of the account |
| 4. Custodial account of a minor (Uniform Gift to Minors Act) | The minor |
| 5. a. The usual revocable savings trust (grantor is also trustee) | The grantor-trustee |
| b. So-called trust account that is not a legal or valid trust under state law | The actual owner |
| 6. Sole proprietorship or disregarded entity owned by an individual | The owner |
| 7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) (A)) | The grantor |
| For this type of account: | Give name and EIN of: | 8. Disregarded entity not owned by an individua | The owner |
| 9. A valid trust, estate, or pension trust | Legal entity |
| 10. Corporation or LLC electing corporate status on Form 8832 or Form 2553 | The corporation |
| 11. Association, club, religious, charitable, educational, or other tax exempt organization | The organization |
| 12. Partnership or multi-member LLC | The partnership |
| 13. A broker or registered nominee | The broker or nominee |
| For this type of account: | Give name and EIN of: |
|---|---|
| 14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments | The public entity | 15. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B)) | The trust |
List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships, earlier
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
- Protect your SSN,
- Ensure your employer is protecting your SSN, and
- Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for Taxpayers.
Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.
Form W-9 (Rev. 10-2018) Page 6
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information
Payment Terms
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| Adress | Corporate: 8765 Stockard Drive, Unit
701-C, Frisco TX 75034 Billing: 1211 North Highway 77, Marietta OK 73448 |
| Toll Free | 855-866-1231 |
| Phone | 469-275-4466 |
| Fax | 855-866-1232 |
| TRADE AND CREDIT REFERENCES | SGT Transportation | Jag Sandhu | 832-769-1145 |
|---|---|---|
| Apex Capitol Corp | Accounts Receivable | 800-511-6022 |
| Compass Funding Solutions | Accounts Receivable | 844-899-8092 |
PLEASE E-MAIL OR FAX BACK THE FOLLOWING BEFORE
WE CAN DISPATCH YOUR TRUCK:
1. OPERATING AUTHORITY
2. CARRIER PROFILE FORM
3. SIGNED BROKER/CARRIER AGREEMENT
4. COPY OF INSURANCE (CARGO & LIABILITY),
SHOWING INTERSTATEX AS THE CERTIFICATE
HOLDER.
5. COMPLETED W-9, SIGNED AND DATED
6. CARRIER REFERENCES
PLEASE NOTE YOU NEED TO BE IN BUSINESS ATLEAST 6
MONTHS TO HAUL FOR INTERSTATE X WITH A
SATISFACTORY
SAFETY RATING.
(hereinafter referred to as “Carrier”) and Kamalsons LLC DBA InterstateX (hereinafter referred to as “Broker”), a licensed property broker pursuant to Docket No. MC#837778.
1. Broker Status. Broker is a freight broker which
arranges for motor carriers to provide cargo
transportation
for its customers, in accordance with its role as
legally defined under 49 U.S.C. § 13102 Definitions
(2),
and
49 C.F.R. §371.2, Broker and Carrier wish for this
Contract to govern Carrier’s performance of motor
transportation services for freight tendered to
Carrier by Broker.
1.1 Carrier Status, Rights and Responsibility.
Carrier will perform its Transportation Services for
Broker
and
its Customers as an independent contractor and will
not for any purpose be the agent of Broker or
Broker’s
Customers. Carrier has exclusive control and
direction of the work Carrier performs pursuant to
this
Agreement.
Carrier will not contract or take other action in
Broker’s name without Broker’s prior written
consent.
Carrier agrees to assume full responsibility for the
payment of all local, state, federal and
intra-provincial
payroll taxes, and contributions or taxes for
unemployment insurance, worker’s compensation
insurance,
pensions,
and other social security or related protection with
respect to the persons engaged by Carrier for
Carrier’s
performance of the transportation and related
services, and Carrier shall indemnify, defend and
hold Broker,
and
its Customer harmless there from. Carrier shall
provide Broker, with Carrier’s Federal Tax ID number
and a
copy
of Carrier’s IRS Form W-9 prior to commencing any
transportation or related services for Broker, under
this
Agreement.
1.2. No Right to Lien or Delay Release of Cargo or
Equipment. Carrier will not assert any lien or make
any
claim
on any cargo or equipment, and no lien will attach
against Broker, its Customers or any cargo or
equipment,
for
failure of Broker, the Customer or any other third
party to pay Carrier for charges due to Carrier.
1.3. Carrier shall, notwithstanding any other terms of this Agreement, expressly waive all rights and remedies under Title 49 U.S.C., Subtitle IV, Part B to the extent they conflict with this Agreement. 2. Booking Confirmation. Carrier shall transport shipments arranged by Broker pursuant to carrier load or Booking confirmation sheet(s) included herewith or subsequently incorporated by reference (See Schedule A annexed hereto).
2.1 Re-Broker. Carrier will not re-broker, assign or interline the shipments hereunder without prior written consent of the Broker. If Carrier breaches this provision, Broker shall have the right of paying the monies it owes Carrier directly to the delivering Carrier, in lieu of payment to Carrier. Upon Broker’s payment to delivering Carrier, Carrier shall not be released from any liability to Broker under this agreement. In addition to the indemnity obligation reflected in this agreement the Carrier will be liable for consequential damages for violation of this clause of the agreement.
3. Compensation. Broker shall pay Carrier for services rendered in an amount equal to the rates and accessorial charges agreed to on the Broker/Carrier Rate Confirmation Sheet or other signed writing. Carrier must submit proof of delivery with invoices to Broker as agent for the shipper. Payment terms shall be thirty (30) days from receipt of necessary supporting documentation.
3.1 Payment of Invoices. Carrier agrees that Broker is the sole party responsible for payment of Carrier’s invoices and that, under no circumstance, will Carrier seek payment from the shipper or consignee.
4. Insurance Evidence. Carrier agrees to provide any insurance coverage’s required by any government body for the types of transportation and related services specified in load confirmation communications received from Broker. All insurance required by this Agreement must be written by an insurance company having a Best’s rating of “B+” VII or better and must be authorized to do business under the laws of the state(s) or province(s) in which Carrier provides the transportation and related services as specified in load confirmation communications received from Broker. Carrier’s insurance shall be primary and required to respond and pay prior to any other available coverage. Carrier agrees that Carrier, Carrier’s insurer(s), and anyone claiming by, through or under Carrier shall have no claim, right of action, or right of subrogation against Broker, its affiliates, or its Customer based on any loss or liability insured under the insurance stipulated herein. Carrier represents and warrants that it will continuously fulfill the requirements of this Section throughout the duration of this Agreement. Broker shall be notified in writing by Carrier’s insurance company at least thirty (30) days prior to the cancellation, change or non-renewal of the submitted insurance policies. Carrier shall at all times during the term of this agreement have and maintain in full force and effect, at its expense, (i) Motor Truck Cargo insurance or a superior equivalent, with limits of not less than US$100,000 per shipment, a deductible no greater than US$2,500 per shipment and at least the same coverage limit and deductible per shipment while in storage or at a storage facility enroute to the consignee, (ii) Commercial Automobile Liability insurance with a combined single limit of not less than US$1,000,000 per occurrence and without aggregate limits, (iii) Commercial General Liability insurance, in a limit of not less than
US$1,000,000 per occurrence, (iv) Worker’s Compensation insurance in the amounts required by statute, and Employer’s Liability insurance with limits not less than US$500,000 per occurrence, and (v) if Carrier provides Transportation Services for hazardous materials under DOT regulations, public insurance required for the commodity transported under 49 C.F.R § 387.7 and 387.9 (or successor regulations thereto). Carrier shall, prior to providing transportation and related services pursuant to this Agreement, name Broker, as a certificate holder. When Carrier provides Transportation Services that involve origins and destinations solely within Canada, Carrier shall be current in its remittances to the appropriate Worker's Compensation Board of the Carrier's province, shall provide a certificate issued by the appropriate Worker's Compensation Board of the Carrier's province certifying that the Carrier is not delinquent and is current in its remittances to that authority, and shall have such other insurance or higher coverage limits required by applicable Canadian national or provincial law or regulation. If Carrier is self-insured, a certificate of the state in which the transportation services are to be performed must be furnished by such state agencies directly to Broker. Insurance will meet or exceed the requirements of federal, state and/or Provincial regulatory bodies having jurisdiction over Carrier’s performances pursuant to this agreement. During this Contract’s term, the insurance policies required hereunder and any replacement policies will (i) insure the interests of Broker and, (ii) cover all drivers, equipment and cargo used in providing Transportation Services and (iii) not contain any exclusions or restrictions as to designated premises or project, pertaining to unattended equipment or cargo, for unscheduled equipment, drivers or cargo, for fraud or infidelity, geographical location in the United States, or for a particular radius of operation.
5. Carrier Moving Perishables. Carrier warrants that the carrier will inspect or hire a service representative to inspect a vehicle’s refrigeration or heating unit at least once each month. Carrier warrants that they shall maintain a record of each inspection of refrigeration or heating unit and retain the records of the inspection for a least one year. Copies of these records must be provided upon request to the carrier’s insurance company and Broker.
Carrier warrants that they will maintain adequate fuel levels for the refrigeration or heating unit and assume full liability for claims and expenses incurred by the Broker or the shipper for failure to do so.
The carrier must provide their cargo insurance carrier with all records that relate to a loss and permit copies and abstracts to be made from them upon request. The following rules shall apply: (a) Destination market value for lost or damaged cargo, no special or consequential damages unless by special agreement; (b) Claims will be filed
with Carrier by Shipper; (c) claims notification procedures will be followed in accordance with procedure described in 49 C.F.R. 370.1-11.
6. Shipping Document Execution. Carriers are to be named on the bill of lading as the “carrier of record.” Broker shall be shown as the third party payer of all freight charges
7. INDEMNIFICATION. CARRIER WILL INDEMNIFY, DEFEND AND HOLD HARMLESS BROKER, ITS AFFILIATES AND ITS CUSTOMERS (AS INTENDED THIRD PARTY BENEFICIARIES) FROM ANY AND AGAINST ALL LOSSES (as defined below) ARISING OUT OF OR IN CONNECTION WITH THE TRANSPORTATION SERVICES PROVIDED UNDER THIS CONTRACT, INCLUDING THE LOADING, UNLOADING, HANDLING, TRANSPORTATION, POSSESSION, CUSTODY, USE OR MAINTENANCE OF CARGO OR EQUIPMENT OR PERFORMANCE OF THIS CONTRACT (INCLUDING BREACH HEREOF) BY CARRIER OR ANY CARRIER REPRESENTATIVE. CARRIER’S OBLIGATION TO INDEMNIFY AND DEFEND SHALL NOT BE AFFECTED BY ALLEGED NEGLIGENCE OR WILLFUL MISCONDUCT OF BROKER, ITS AFFILIATES OR CUSTOMERS. IT IS THE INTENT OF THE PARTIES THAT THIS PROVISION BE CONSTRUED TO PROVIDE INDEMNIFICATION TO BROKER, ITS AFFILIATES AND CUSTOMERS TO THE MAXIMUM EXTENT PERMITTED BY LAW. IF THIS PROVISION IS FOUND IN ANY WAY TO BE OVERBROAD, IT IS THE PARTIES INTENT THAT THIS PROVISION BE ENFORCED TO ALLOW INDEMNIFICATION TO THE MAXIMUM EXTENT PERMISSABLE. “Losses” mean any and all losses, liabilities, obligations, personal injury, bodily injury, property damage, loss or theft of property, damages, penalties, actions, causes of action, claims, suits, demands, costs and expenses of any nature whatsoever, including reasonable attorneys’ and paralegals’ fees and other costs of defense, investigation and settlement, costs of containment, cleanup and remediation of spills, releases or other environmental contamination and costs of enforcement of indemnity obligations.
8. Carrier’s Cargo Liability. Carrier assumes full liability for the greater of replacement cost or invoice value for loss, damage or destruction of any and all goods or property tendered to Carrier by Broker, while under Carrier’s care, custody or control. Carrier shall inspect each load at the time it is tendered to Carrier to assure its condition. If Carrier is tendered a load which is not in suitable condition, it shall notify Broker, immediately. Cargo which has been tendered to Carrier intact and released by Carrier in a damaged condition, or lost or destroyed subsequent to such tender to Carrier, shall be conclusively presumed to have been lost, damaged or destroyed by Carrier unless Carrier can establish otherwise by clear and convincing evidence. Carrier shall either pay Broker, directly or allow Broker, to deduct from the amount Broker, owes Carrier, Customer’s full actual loss, or the amount determined by Broker, and Carrier to be
Carrier’s responsibility. Carrier agrees that it will assert no lien against cargo transported hereunder. Broker, shall deduct from the amount Broker otherwise owes Carrier, the Customer’s full actual loss of all claims that are not resolved within ninety (90) days of the date of the claim. Carrier agrees to indemnify Broker, for any payments made hereunder. In the event of an accident, Carrier shall notify Broker immediately for further instructions. Carrier shall return all damaged shipments at its expense to the point of origin or to other points as instructed by Broker.
8.1 Salvage Claims. Carrier shall waive any and all right of salvage or resale of any of Customer’s damaged goods and shall, at Broker’s reasonable request and direction, promptly return or dispose, at Carrier’s cost, any and all of Customer’s damaged and goods shipped by Carrier. Carrier shall not under any circumstance allow Customer’s goods to be sold or made available for sale or otherwise disposed of in any salvage markets, employee stores, or any other secondary outlets. In the event that damaged goods are returned to Customer and salvaged by Customer, Carrier shall receive a credit for the actual salvage value of such goods
9. Law and Integration. This written Agreement, together with any load confirmation, contains the entire agreement between the parties and may only be modified by signed written agreement. State law, venue and jurisdiction shall apply in Love County, State of Oklahoma.
9.1 Safety Rating. Carrier shall endeavor to maintain a satisfactory U.S. DOT Safety Rating but under no circumstances is Carrier allowed to provide services under this contract if their safety rating falls to “unsatisfactory” .
10. Confidentiality Obligations. Carrier acknowledges that in carrying out this Contract, it will learn proprietary information about Broker and its business, including its rates, services, personnel, computer systems, Customers, traffic volumes, origins and destinations, commodity types, shipment information and business practices (the “Information”). During this Contract’s term and for 12 months after its termination, Carrier will hold the Contract provisions and Information in confidence, restrict disclosure to those Carrier Representatives with a need to know, and not use the Information to Broker’s competitive detriment or for any purpose except as contemplated hereby. Carrier may disclose Information to the extent required by a governmental agency or under a court order, provided that Carrier notifies Broker of such requirements before disclosure.
10.1. Nonsolicitation of Customers. During this Contract’s term and for 24 months after its termination, Carrier will not, and will cause the Carrier Representatives not, to directly or indirectly solicit or provide transportation services to any Customer without Broker’s
prior written consent if (a) that Customer first became known to Carrier as a result of Broker’s engagement of Carrier, (b) the type of transportation services, such as the
origins and destinations served or commodity types,
provided to that Customer first
became known to Carrier as a result of Broker’s
engagement of Carrier or (c) the first
shipment transported by Carrier for that Customer
was tendered to Carrier by Broker. If
Carrier or any Carrier Representative solicits a
Customer in violation of this Section,
Carrier shall pay to Broker as a commission 10% of
the total charges, with a maximum of
US$1000 per shipment, for transportation services
provided by Carrier to such Customer.
11. Savings Clause. If any provision of this
Agreement or any Transportation Schedule
is held to be invalid, the remainder of the
Agreement or the Transportation Schedule shall
remain in force and effect with the offensive term
or condition being stricken to the
extent necessary to comply with any conflicting law.
12. This Agreement shall be for the period of one (1) year and shall be automatically renewed unless cancelled. Either party may terminate this Agreement upon fifteen (15) days written notice.
Broker: InterstateX
Print Name: Amara A Kamal
Title: CEO
ADDENDUM TO CONTRACT
BROKER-CARRIER AGREEMENT
THIS ADDENDUM TO BROKER-CARRIER AGREEMENT is entered into as of
by and Interstate X, an Oklahoma Limited Liability Company ("Broker"), a Registered Property Broker, Lic.No. MC 837778, and
a Registered Motor Carrier , Permit/Certificate No. DOT -
("Carrier"), collectively the "Parties". WHEREAS, Broker and Carrier entered into that certain Broker-Carrier agreement, date
(the "Carrier Agreement") pursuant to which, among other things, Carrier agreed to furnish transportation of commodities in connect with Broker's business, including food items (the "Food"): and
WHEREAS, Broker and Carrier desire to supplement certain terms of the Broker-Carrier Agreement with respect to, among other things, Carrier's provisions of the Services (as defined in the Broker-Carrier Agreement).
NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
Section 1 F shall now read and state: Is in, and shall maintain, compliance during the term of this Agreement, with all applicable federal, state and local laws relating to the provision of its services including, but not limited to: training of drivers, transportation of Hazardous Materials, (including the licensing and training of Haz Mat qualified drivers), as defined in 49 C.F.R. §172.800, §173, and §397 et seq. to the extent that any shipments hereunder constitute Hazardous Materials; security regulations; owner/operator lease regulations; loading and securement of freight regulations; implementation and maintenance of driver safety regulations including, but not limited to, hiring, controlled substances, and hours of service regulations; sanitation, temperature, and contamination requirements for transporting food, perishable, and other products, including without limitation the Food Safety Modernization Act, the Sanitary Food Transportation Act of 2005 and the FDA'a Final Rule pertaining to Sanitary Transportation of Human and Animal Food, qualification and licensing and training of drivers; implementation and maintenance of equipment safety regulations; maintenance and control of the means and method of transportation including, but not limited to, performance of its drivers; all applicable insurance laws and regulations including, but not limited to workers’ compensation. Upon request, CARRIER agrees to provide documentation as to proof of training and compliance.
Section 3 A shall now read and state: EQUIPMENT: Subject to its representations and warranties in Paragraph 1 above, CARRIER agrees to provide the necessary equipment and qualified personnel for completion of the transportation services required for BROKER and/or its customers. CARRIER will not supply equipment that has been used to transport hazardous wastes, solid or liquid, regardless of whether they meet the definition in 40 C.F.R. §261.1 et. seq. CARRIER agrees that all shipments will be transported and delivered with reasonable dispatch, or as otherwise agreed in writing.
Section 3 C (i) shall now read and state: shall comply with 49 C.F.R. §370.1 et seq. and any amendments and/or any other applicable regulations adopted by the Federal Motor Carrier Safety Administration, U.S. Department of Transportation, or any applicable state regulatory agency, for processing all loss and damage claims and salvage. CARRIER agrees that food that has been transported or offered for transport under conditions that are not in compliance with Shipper's or BROKER'S instructions, as provided to CARRIER by Shipper or BROKER, will be considered "adulterated" within the meaning of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 342 (i). CARRIER understands and agrees that adulterated shipment may be refused by the consignee or receiver, at destination without diminishing or affecting CARRIER'S liability in the event of a cargo claim. CARRIER shall not sell, salvage or attempt to sell or salvage any goods without the BROKER’s express, written permission; and
IN WITNESS WHEREOF, we have signed this Agreement the date and year first shown above.
Broker: InterstateX
By:
Print Name: Amara A Kamal
Title: CEO
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