Form W-9 (Rev. 1-2003) Page 4Part II. CertificationTo establish to the withholding agent that you are a U.S.person, or resident alien, sign Form W-9. You may berequested to sign by the withholding agent even if items 1, 3,and 5 below indicate otherwise.For a joint account, only the person whose TIN is shown inPart I should sign (when required). Exempt recipients, seeExempt from backup withholding on page 2.Signature requirements. Complete the certification asindicated in 1 through 5 below.1. <strong>In</strong>terest, dividend, and barter exchange accountsopened before 1984 and broker accounts consideredactive during 1983. You must give your correct TIN, but youdo not have to sign the certification.2. <strong>In</strong>terest, dividend, broker, and barter exchangeaccounts opened after 1983 and broker accountsconsidered inactive during 1983. You must sign thecertification or backup withholding will apply. If you aresubject to backup withholding and you are merely providingyour correct TIN to the requester, you must cross out item 2in the certification before signing the form.3. Real estate transactions. You must sign thecertification. You may cross out item 2 of the certification.4. Other payments. You must give your correct TIN, butyou do not have to sign the certification unless you havebeen notified that you have previously given an incorrect TIN.“Other payments” include payments made in the course ofthe requester’s trade or business for rents, royalties, goods(other than bills for merchandise), medical and health careservices (including payments to corporations), payments to anonemployee for services, payments to certain fishing boatcrew members and fishermen, and gross proceeds paid toattorneys (including payments to corporations).5. Mortgage interest paid by you, acquisition orabandonment of secured property, cancellation of debt,qualified tuition program payments (under section 529),IRA or Archer MSA contributions or distributions, andpension distributions. You must give your correct TIN, butyou do not have to sign the certification.What Name and Number To Give theRequesterFor this type of account:1. <strong>In</strong>dividual2. Two or more individuals (jointaccount)3. Custodian account of a minor(Uniform Gift to Minors Act)4. a. The usual revocablesavings trust (grantor isalso trustee)b. So-called trust accountthat is not a legal or validtrust under state law5. Sole proprietorship orsingle-owner LLCFor this type of account:6.7.8.9.Sole proprietorship orsingle-owner LLCA valid trust, estate, orpension trustCorporate or LLC electingcorporate status on Form8832Association, club, religious,charitable, educational, orother tax-exempt organization10. Partnership or multi-memberLLC11. A broker or registerednominee12. Account with the Departmentof Agriculture in the name ofa public entity (such as astate or local government,school district, or prison) thatreceives agricultural programpaymentsGive name and SSN of:The individualThe actual owner of the accountor, if combined funds, the firstindividual on the account 1The minor 2The grantor-trustee 1The actual owner 1The owner 3Give name and EIN of:The owner 3Legal entity 4The corporationThe organizationThe partnershipThe broker or nomineeThe public entity1List first and circle the name of the person whose number you furnish. If onlyone person on a joint account has an SSN, that person’s number must befurnished.2Circle the minor’s name and furnish the minor’s SSN.3You must show your individual name, but you may also enter yourbusiness or “DBA” name. You may use either your SSN or EIN (if you haveone).4List first and circle the name of the legal trust, estate, or pension trust. (Donot furnish the TIN of the personal representative or trustee unless the legalentity itself is not designated in the account title.)Note: If no name is circled when more than one name islisted, the number will be considered to be that of the firstname listed.Privacy Act NoticeSection 6109 of the <strong>In</strong>ternal Revenue Code requires you to provide your correct TIN to persons who must file information returnswith the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition orabandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses thenumbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this informationto the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out theirtax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforceFederal nontax criminal laws and to combat terrorism.You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxableinterest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.Page 58
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTI/we hereby authorize LogistiCare Solutions, LLC (“The Company”) to initiate electronic credit entries tothe financial institution and account indicated below. I/we further authorize “The Company” to initiateelectronic debit entries to the account listed below to correct any errors. This authority is to remain in fullforce and effect until “The Company” has received written notification to terminate the agreement. Allchanges must be submitted in writing and may require a new EFT agreement.Section 1 (To be completed by the <strong>Transportation</strong> <strong>Provider</strong>)Type of Transaction: ____ Add ____ Change ____ Delete<strong>Transportation</strong> <strong>Provider</strong> Name: ______________________________________________________Address: ____________________________________________________________________________________________________________Telephone Number: ______________________________________________________Federal Tax Identification Number: __________________________________________________Authorize Signer Name: ___________________________________________________________Authorize Signature: ______________________________________________________________Section 2 (To be completed by the Financial <strong>In</strong>stitution)Direct Deposit to be made to: ________________________________________________________Financial <strong>In</strong>stitution Name: _________________________________________________________Address: __________________________________________________________________________________________________________________Telephone Number: _________________________________________________________Routing & Transit Number/ABA #: __________________________________________________Account Number (<strong>Transportation</strong> <strong>Provider</strong>): __________________________________________Bank Official Signature: ________________________________ Date: _____________________Section 3 (To be completed by the LogistiCare Solutions, LLC)Date Received: ______________________ Vendor Code: ________________________________A/P Approval: _______________________ Treasury Approval: ___________________________PLEASE ATTACH VOIDED CHECK HERENo Counter/Starter ChecksPage 59
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