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Submitted URL: https://secure.rm.edu/
Effective URL: https://secure.rm.edu/w9-dd-auth/
Submission: On July 23 via automatic, source certstream-suspicious — Scanned from US
Effective URL: https://secure.rm.edu/w9-dd-auth/
Submission: On July 23 via automatic, source certstream-suspicious — Scanned from US
Form analysis 1 forms found in the DOM
POST /w9-dd-auth/#gf_1
<form method="post" enctype="multipart/form-data" id="gform_1" action="/w9-dd-auth/#gf_1" data-formid="1" novalidate="">
<div id="gf_page_steps_1" class="gf_page_steps">
<div id="gf_step_1_1" class="gf_step gf_step_active gf_step_first"><span class="gf_step_number">1</span><span class="gf_step_label"></span></div>
<div id="gf_step_1_2" class="gf_step gf_step_next gf_step_pending gf_step_hidden"><span class="gf_step_number">2</span><span class="gf_step_label">W9</span></div>
<div id="gf_step_1_3" class="gf_step gf_step_last gf_step_pending gf_step_hidden"><span class="gf_step_number">3</span><span class="gf_step_label">Direct Deposit Authorization</span></div>
</div>
<div class="gform-body gform_body">
<div id="gform_page_1_1" class="gform_page " data-js="page-field-id-1">
<div class="gform_page_fields">
<div id="gform_fields_1" class="gform_fields top_label form_sublabel_below description_above validation_below">
<div id="field_1_2" class="gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_2">
<h3 class="gsection_title"></h3>
<div class="gsection_description" id="gfield_description_1_2">
<p>Welcome to the secure data collection portal. The W9 is a US Government Form called ‘Request for Taxpayer Identification Number’. In order to meet IRS compliance, we are required to collect this W9 information before we can setup a
vendor in our accounting system. Our current payment method to vendors is Direct Deposit, so the second portion of this form is the Direct Deposit Authorization form. The purpose of collecting this information is to expedite the
payment process to our vendors. If you have any questions or concerns, please feel free to reach out to the Finance Office at <a href="mailto:" financeoffice@rm.edu"="">financeoffice@rm.edu</a> or
<a href="tel:8013755125">801-375-5125</a> Option 5.</p>
</div>
</div>
<fieldset id="field_1_35" class="gfield gfield--type-name field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_35">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Name</legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_1_35">
<span id="input_1_35_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_35.3" id="input_1_35_3" value="" aria-required="false">
<label for="input_1_35_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_1_35_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_35.6" id="input_1_35_6" value="" aria-required="false">
<label for="input_1_35_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</fieldset>
<fieldset id="field_1_4" class="gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_4">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="gfield_description" id="gfield_description_1_4">Please provide your primary email address</div>
<div class="ginput_complex ginput_container ginput_container_email gform-grid-row" id="input_1_4_container">
<span id="input_1_4_1_container" class="ginput_left gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_4" id="input_1_4" value="" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_1_4">
<label for="input_1_4" class="gform-field-label gform-field-label--type-sub ">Enter Email</label>
</span>
<span id="input_1_4_2_container" class="ginput_right gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_4_2" id="input_1_4_2" value="" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_1_4">
<label for="input_1_4_2" class="gform-field-label gform-field-label--type-sub ">Confirm Email</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<div id="field_1_37" class="gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_37"><label
class="gfield_label gform-field-label" for="input_1_37">Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_1_37">Please provide your primary phone number</div>
<div class="ginput_container ginput_container_phone"><input name="input_37" id="input_1_37" type="tel" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_1_37"></div>
</div>
<fieldset id="field_1_23" class="gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_23">
<legend class="gfield_label gform-field-label">Please select the appropriate response</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_23">
<div class="gchoice gchoice_1_23_0">
<input class="gfield-choice-input" name="input_23" type="radio" value="I need to submit a W9 and Direct Deposit Authorization" id="choice_1_23_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_0" id="label_1_23_0" class="gform-field-label gform-field-label--type-inline">I need to submit a W9 and Direct Deposit Authorization</label>
</div>
<div class="gchoice gchoice_1_23_1">
<input class="gfield-choice-input" name="input_23" type="radio" value="I have already submitted a W9, but need to update my Direct Deposit Information" id="choice_1_23_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_1" id="label_1_23_1" class="gform-field-label gform-field-label--type-inline">I have already submitted a W9, but need to update my Direct Deposit Information</label>
</div>
<div class="gchoice gchoice_1_23_2">
<input class="gfield-choice-input" name="input_23" type="radio" value="I only need to submit a W9 because I cannot accept direct deposit as a payment method" id="choice_1_23_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_23_2" id="label_1_23_2" class="gform-field-label gform-field-label--type-inline">I only need to submit a W9 because I cannot accept direct deposit as a payment method</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_next_button_1_1" class="gform_next_button gform-theme-button button" value="Submit"
onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_2" class="gform_page" data-js="page-field-id-1" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_2" class="gform_fields top_label form_sublabel_below description_above validation_below">
<div id="field_1_5" class="gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_5">
<h3 class="gsection_title">W9</h3>
<div class="gsection_description" id="gfield_description_1_5"><a href="https://www.irs.gov/pub/irs-pdf/fw9.pdf" target="_blank">Full W9 Instructions can be viewed here</a></div>
</div>
<div id="field_1_30" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_30"><label
class="gfield_label gform-field-label" for="input_1_30">Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_1_30">Name (as shown on your income tax return). Name is required; do not leave this line blank.</div>
<div class="ginput_container ginput_container_text"><input name="input_30" id="input_1_30" type="text" value="" class="medium" aria-describedby="gfield_description_1_30" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_1_17" class="gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_17"><label
class="gfield_label gform-field-label" for="input_1_17">Business Name (if applicable)</label>
<div class="gfield_description" id="gfield_description_1_17">Disregarded entity name, if different from above</div>
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_1_17" type="text" value="" class="medium" aria-describedby="gfield_description_1_17" aria-invalid="false"> </div>
</div>
<fieldset id="field_1_15" class="gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_15">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row" id="input_1_15">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_1_15_1_container">
<input type="text" name="input_15.1" id="input_1_15_1" value="" aria-required="true">
<label for="input_1_15_1" id="input_1_15_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_1_15_3_container">
<input type="text" name="input_15.3" id="input_1_15_3" value="" aria-required="true">
<label for="input_1_15_3" id="input_1_15_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_1_15_4_container">
<input type="text" name="input_15.4" id="input_1_15_4" value="" aria-required="true">
<label for="input_1_15_4" id="input_1_15_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_1_15_5_container">
<input type="text" name="input_15.5" id="input_1_15_5" value="" aria-required="true">
<label for="input_1_15_5" id="input_1_15_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP / Postal Code</label>
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_1_15_6_container">
<select name="input_15.6" id="input_1_15_6" aria-required="true">
<option value="" selected="selected"></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czechia">Czechia</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Eswatini">Eswatini</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See">Holy See</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Macedonia">North Macedonia</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria Arab Republic">Syria Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Türkiye">Türkiye</option>
<option value="US Minor Outlying Islands">US Minor Outlying Islands</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Åland Islands">Åland Islands</option>
</select>
<label for="input_1_15_6" id="input_1_15_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<fieldset id="field_1_24" class="gfield gfield--type-radio gfield--type-choice gf_list_4col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_1_24">
<legend class="gfield_label gform-field-label">Tax Classification<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="gfield_description" id="gfield_description_1_24">Select appropriate box for federal tax classification of the person whose name is entered above.</div>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_24">
<div class="gchoice gchoice_1_24_0">
<input class="gfield-choice-input" name="input_24" type="radio" value="Individual/sole proprietor or single-member LLC" id="choice_1_24_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_24">
<label for="choice_1_24_0" id="label_1_24_0" class="gform-field-label gform-field-label--type-inline">Individual/sole proprietor or single-member LLC</label>
</div>
<div class="gchoice gchoice_1_24_1">
<input class="gfield-choice-input" name="input_24" type="radio" value="C Corporation" id="choice_1_24_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_1" id="label_1_24_1" class="gform-field-label gform-field-label--type-inline">C Corporation</label>
</div>
<div class="gchoice gchoice_1_24_2">
<input class="gfield-choice-input" name="input_24" type="radio" value="S Corporation" id="choice_1_24_2" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_2" id="label_1_24_2" class="gform-field-label gform-field-label--type-inline">S Corporation</label>
</div>
<div class="gchoice gchoice_1_24_3">
<input class="gfield-choice-input" name="input_24" type="radio" value="Partnership" id="choice_1_24_3" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_3" id="label_1_24_3" class="gform-field-label gform-field-label--type-inline">Partnership</label>
</div>
<div class="gchoice gchoice_1_24_4">
<input class="gfield-choice-input" name="input_24" type="radio" value="Trust/estate" id="choice_1_24_4" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_4" id="label_1_24_4" class="gform-field-label gform-field-label--type-inline">Trust/estate</label>
</div>
<div class="gchoice gchoice_1_24_5">
<input class="gfield-choice-input" name="input_24" type="radio" value="Limited liability company" id="choice_1_24_5" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_5" id="label_1_24_5" class="gform-field-label gform-field-label--type-inline">Limited liability company</label>
</div>
<div class="gchoice gchoice_1_24_6">
<input class="gfield-choice-input" name="input_24" type="radio" value="gf_other_choice" id="choice_1_24_6" onchange="gformToggleRadioOther( this )">
<label for="choice_1_24_6" id="label_1_24_6" class="gform-field-label gform-field-label--type-inline">Other</label><br><input id="input_1_24_other" class="gchoice_other_control" name="input_24_other" type="text" value="Other"
aria-label="Other Choice, please specify" disabled="disabled">
</div>
</div>
</div>
</fieldset>
<div id="field_1_25" class="gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_25"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_1_25">Enter the Tax Classification for your Limited liability company<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_25" id="input_1_25" class="medium gfield_select" aria-required="true" aria-invalid="false" disabled="disabled">
<option value="C">C corporation</option>
<option value="S">S corporation</option>
<option value="P">Partnership</option>
</select></div>
</div>
<div id="field_1_28" class="gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_28">
<h3 class="gsection_title">Part I Taxpayer Identification Number (TIN)</h3>
<div class="gsection_description" id="gfield_description_1_28">Enter your TIN. 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.</div>
</div>
<fieldset id="field_1_29" class="gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_1_29">
<legend class="gfield_label gform-field-label">Which TIN will you be providing?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_29">
<div class="gchoice gchoice_1_29_0">
<input class="gfield-choice-input" name="input_29" type="radio" value="Social Security Number (SSN)" id="choice_1_29_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_29_0" id="label_1_29_0" class="gform-field-label gform-field-label--type-inline">Social Security Number (SSN)</label>
</div>
<div class="gchoice gchoice_1_29_1">
<input class="gfield-choice-input" name="input_29" type="radio" value="Employer Identification Number (EIN)" id="choice_1_29_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_29_1" id="label_1_29_1" class="gform-field-label gform-field-label--type-inline">Employer Identification Number (EIN)</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_22" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_22"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_1_22">Social security number<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_1_22">Please provide your Social Security Number (SSN)</div>
<div class="ginput_container ginput_container_text"><input name="input_22" id="input_1_22" type="text" value="" class="medium" aria-describedby="gfield_description_1_22" placeholder="###-##-####" aria-required="true" aria-invalid="false"
disabled="disabled"> </div>
</div>
<div id="field_1_26" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_26"
data-conditional-logic="hidden" style="display: none;"><label class="gfield_label gform-field-label" for="input_1_26">Employer identification number<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_1_26">Please provide Employer identification number (EIN)</div>
<div class="ginput_container ginput_container_text"><input name="input_26" id="input_1_26" type="text" value="" class="medium" aria-describedby="gfield_description_1_26" placeholder="##-#######" aria-required="true" aria-invalid="false"
disabled="disabled"> </div>
</div>
<div id="field_1_31" class="gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_31">
<h3 class="gsection_title">Part II Certification</h3>
<div class="gsection_description" id="gfield_description_1_31">Under penalties of perjury, I certify that: <ol>
<li>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</li>
<li>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</li>
<li>3. I am a U.S. citizen or other U.S. person (defined below); and</li> 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
</ol>
<strong>Certification instructions.</strong> 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.
</div>
</div>
<div id="field_1_33" class="gfield gfield--type-signature field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_33"><label
class="gfield_label gform-field-label" for="input_1_33">Sign Here</label>
<div class="gfield_description" id="gfield_description_1_33">Signature of U.S. person</div>
<div class="gfield_signature_ui_container gform-theme__no-reset--children">
<div id="input_1_33_Container" class="gfield_signature_container ginput_container" style="height: 180px; z-index: 99; width: 0px;"><input type="hidden" class="gform_hidden" name="input_1_33_valid" id="input_1_33_valid"><canvas
id="input_1_33" width="0" height="180"
style="border-width: 2px; border-style: dashed; border-color: rgb(221, 221, 221); background-color: rgb(255, 255, 255); cursor: url("https://secure.rm.edu/wp-content/plugins/gravityformssignature/includes/super_signature/pen.cur"), pointer; height: 180px; width: 0px;"></canvas>
</div>
<div id="input_1_33_toolbar" style="margin: 5px; position: relative; height: 20px; background-color: transparent; width: 0px;"><img id="input_1_33_resetbutton"
src="https://secure.rm.edu/wp-content/plugins/gravityformssignature/includes/super_signature/refresh.png" style="cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent" alt="Clear Signature">
<div id="input_1_33_status" style="color: blue; height: 20px; width: auto; padding: 2px; font-family: verdana; font-size: 12px; float: left; margin-right: 30px; display: none;"></div><input type="hidden" id="input_1_33_data"
name="input_1_33_data" value=""><input type="hidden" id="input_1_33_data_smooth" name="input_1_33_data_smooth" value=""><input type="hidden" id="input_1_33_data_canvas" name="input_1_33_data_canvas" value=""><button type="button"
id="input_1_33_lockedReset" class="gform_signature_locked_reset gform-theme-no-framework"
style="color: var(--gform-theme-control-description-color);display:none;height:24px;cursor:pointer;padding: 0 0 0 1.8em;opacity:0.75;font-size:0.813em;border:0;background: transparent url(data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIHZpZXdCb3g9IjAgMCA0NDggNTEyIiBjbGFzcz0idW5kZWZpbmVkIj48cGF0aCBkPSJNNDAwIDIyNGgtMjR2LTcyQzM3NiA2OC4yIDMwNy44IDAgMjI0IDBTNzIgNjguMiA3MiAxNTJ2NzJINDhjLTI2LjUgMC00OCAyMS41LTQ4IDQ4djE5MmMwIDI2LjUgMjEuNSA0OCA0OCA0OGgzNTJjMjYuNSAwIDQ4LTIxLjUgNDgtNDhWMjcyYzAtMjYuNS0yMS41LTQ4LTQ4LTQ4em0tMTA0IDBIMTUydi03MmMwLTM5LjcgMzIuMy03MiA3Mi03MnM3MiAzMi4zIDcyIDcydjcyeiIgY2xhc3M9InVuZGVmaW5lZCIvPjwvc3ZnPg==) no-repeat left center;background-size:16px;float:left;direction:ltr;">Reset
to re-sign.</button>
</div>
</div>
</div>
<div id="field_1_36" class="gfield gfield--type-pdfpreview field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_36"><label
class="gfield_label gform-field-label" for="input_1_36">PDF Preview</label>
<div id="input_1_36" class="gpdf-previewer-wrapper gform-theme__no-reset--children" data-field-id="36" data-pdf-id="5cf6ee029121c"
data-settings="{"height":600,"download":false,"theme":"dark","zoomLevel":"page-width","pageScrolling":"vertical","spread":"none","rightClickProtection":true,"textCopyingProtection":true,"rtl":false}">
</div>
</div>
<div id="field_1_34" class="gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_34">
<div class="ginput_container ginput_container_text"><input name="input_34" id="input_1_34" type="hidden" class="gform_hidden" aria-invalid="false" value=""></div>
</div>
<div id="field_1_19" class="gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible" data-js-reload="field_1_19">
<div class="ginput_container ginput_container_text"><input name="input_19" id="input_1_19" type="hidden" class="gform_hidden" aria-invalid="false" value="Rocky Mountain University of Health Professions"></div>
</div>
<fieldset id="field_1_21" class="gfield gfield--type-address field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden" data-js-reload="field_1_21">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<legend class="gfield_label gform-field-label gfield_label_before_complex">Requester Address</legend>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row" id="input_1_21">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_1_21_1_container">
<input type="text" name="input_21.1" id="input_1_21_1" value="122 E 1700 S" aria-required="false">
<label for="input_1_21_1" id="input_1_21_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2 gform-grid-col" id="input_1_21_2_container">
<input type="text" name="input_21.2" id="input_1_21_2" value="" aria-required="false">
<label for="input_1_21_2" id="input_1_21_2_label" class="gform-field-label gform-field-label--type-sub ">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_1_21_3_container">
<input type="text" name="input_21.3" id="input_1_21_3" value="Provo" aria-required="false">
<label for="input_1_21_3" id="input_1_21_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_1_21_4_container">
<input type="text" name="input_21.4" id="input_1_21_4" value="UT" aria-required="false">
<label for="input_1_21_4" id="input_1_21_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_1_21_5_container">
<input type="text" name="input_21.5" id="input_1_21_5" value="84606" aria-required="false">
<label for="input_1_21_5" id="input_1_21_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP / Postal Code</label>
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_1_21_6_container">
<select name="input_21.6" id="input_1_21_6" aria-required="false">
<option value="" selected="selected"></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czechia">Czechia</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Eswatini">Eswatini</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See">Holy See</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Macedonia">North Macedonia</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria Arab Republic">Syria Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Türkiye">Türkiye</option>
<option value="US Minor Outlying Islands">US Minor Outlying Islands</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Åland Islands">Åland Islands</option>
</select>
<label for="input_1_21_6" id="input_1_21_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
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<h3 class="gsection_title">Direct Deposit</h3>
</div>
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data-js-reload="field_1_9"><label class="gfield_label gform-field-label" for="input_1_9">Bank Routing Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
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data-js-reload="field_1_10"><label class="gfield_label gform-field-label" for="input_1_10">Confirm Bank Routing Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_10" id="input_1_10" type="text" value="" class="medium" placeholder="#########" aria-required="true" aria-invalid="false"> </div>
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<div class="ginput_container ginput_container_number"><input name="input_14" id="input_1_14" type="number" step="any" value="" class="medium" placeholder="#################" aria-required="true" aria-invalid="false"></div>
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</form>Text Content
Advancing Knowledge, Advancing Healthcare
W9 & DIRECT DEPOSIT AUTHORIZATION
"*" indicates required fields
1
2W9
3Direct Deposit Authorization
Welcome to the secure data collection portal. The W9 is a US Government Form
called ‘Request for Taxpayer Identification Number’. In order to meet IRS
compliance, we are required to collect this W9 information before we can setup a
vendor in our accounting system. Our current payment method to vendors is Direct
Deposit, so the second portion of this form is the Direct Deposit Authorization
form. The purpose of collecting this information is to expedite the payment
process to our vendors. If you have any questions or concerns, please feel free
to reach out to the Finance Office at financeoffice@rm.edu or 801-375-5125
Option 5.
Name
First Last
Email*
Please provide your primary email address
Enter Email Confirm Email
Phone*
Please provide your primary phone number
Please select the appropriate response
I need to submit a W9 and Direct Deposit Authorization
I have already submitted a W9, but need to update my Direct Deposit Information
I only need to submit a W9 because I cannot accept direct deposit as a payment
method
W9
Full W9 Instructions can be viewed here
Name*
Name (as shown on your income tax return). Name is required; do not leave this
line blank.
Business Name (if applicable)
Disregarded entity name, if different from above
Address*
Street Address City State / Province / Region ZIP / Postal Code
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua
and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire,
Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish
Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo
VerdeCambodiaCameroonCanadaCayman IslandsCentral African
RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo,
Democratic Republic of theCook IslandsCosta
RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican
RepublicEcuadorEgyptEl SalvadorEquatorial
GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and McDonald IslandsHoly SeeHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic
People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic
RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth
MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State
ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena,
Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint
Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and
PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint
MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the
South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan
MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United
Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying
IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited
StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin
Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Country
Tax Classification*
Select appropriate box for federal tax classification of the person whose name
is entered above.
Individual/sole proprietor or single-member LLC
C Corporation
S Corporation
Partnership
Trust/estate
Limited liability company
Other
Enter the Tax Classification for your Limited liability company*
C corporationS corporationPartnership
PART I TAXPAYER IDENTIFICATION NUMBER (TIN)
Enter your TIN. 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 TIN will you be providing?*
Social Security Number (SSN)
Employer Identification Number (EIN)
Social security number*
Please provide your Social Security Number (SSN)
Employer identification number*
Please provide Employer identification number (EIN)
PART II CERTIFICATION
Under penalties of perjury, I certify that:
1. 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. 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. 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.
Sign Here
Signature of U.S. person
Reset to re-sign.
PDF Preview
Hidden
Requester Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua
and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire,
Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish
Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo
VerdeCambodiaCameroonCanadaCayman IslandsCentral African
RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo,
Democratic Republic of theCook IslandsCosta
RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican
RepublicEcuadorEgyptEl SalvadorEquatorial
GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and McDonald IslandsHoly SeeHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic
People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic
RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth
MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State
ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena,
Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint
Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and
PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint
MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the
South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan
MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United
Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying
IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited
StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin
Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Country
DIRECT DEPOSIT
Bank Routing Number*
Confirm Bank Routing Number*
Account Number*
Confirm Account Number*
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