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<br />FRM4-M (Rev 5-03) <br /> <br />TAXPAYER IDENTIFICATION NUMBER <br /> <br />WBS ELEMENT: 37858 <br />PROJECT: MA 10022 B <br />TIP No.: MA 10022 B <br />PARCEL No.: MA 10022 B 002 <br />COUNTY: Cabarrus <br /> <br />Pursuant to Internal Revenue Service Regulations, vendors must furnish their Taxpayer Identification <br />Number (TIN) to the State. If this number is not provided, you may be subject to a 20% withholding on <br />each payment. To avoid this 20% withholding and to insure that accurate tax information is reported to <br />the Internal Revenue Service and the State, please use this form to provide the requested information <br />exactly as it appears on file with the IRS. <br /> <br />Legal Business/Individual Name: <br /> <br />Address: <br /> <br />9 Digit Taxpayer Identification Number: <br />Social Security Number <br />OR <br />Federal Employer Identification Number <br /> <br />Special Interest Group (Check One, if applicable) <br />Large Business <br />Minority Owned <br />Woman Owned <br />Handicap Owned <br />Disabled Owned <br />Small Business <br /> <br />Business Designation (Check One) <br />Individual SS# <br />Sole Proprietorship SS# <br />Partnership <br />Estaterrrust <br />Corporation Fed ID# <br />Public Service Corporation FED ID# <br />Governmental/Non-Profit <br /> <br />Under penalties of perjury, I declare that I have examined this request and to the best of my knowledge <br />and belief, it is true, correct and complete. The IRS has not notified me that I am subject to backup <br />withholding for failure to report income. <br /> <br />Name (Print or Type) <br /> <br />Title (Print or Type) <br /> <br />Must Sign <br /> <br />Signature <br /> <br />Date <br /> <br />Telephone Number <br /> <br />To avoid payment delays, completed form should be returned promptly to: <br />NC Department of Transportation <br />Right of Way Branch <br />206 Charter Street, Albemarle, NC 28001 <br /> <br />SPECIAL INTEREST GROUP DEFINITIONS: <br />Minority Owned (At least 51 % of which is owned and controlled by minority group member (Black, Asian, <br />Hispanic, American Indian), <br />Woman Owned (51% and controlled by Women) <br />Handicapped Owned (51 % owned & controlled by a Physically Handicapped Person) <br />Disabled Owned (51% owned & controlled by a Disabled Person) <br />Small Business (Less than 100 Employees & yearly sales Less than $500,000.00) <br /> <br />June 2003 <br /> <br />r-;p <br />