DSHA requires the following information for all vendors (payees) before any payment can be made. This information is used to populate and maintain DSHA's vendor file.

New Vendor Change Profile Additional Address

*Taxpayer ID: SSN EIN
- -

If a Foreign company, use IRS FormW-8 available at
*Payment Method: DSHA reserves the right to provide payment by any of the following methods: credit card, ACH, or by check, at DSHA's option.
*Can you accept payment by credit card? Yes No
Applicant Information:
  *Applicant Name
(individual or entity):
  Name on IRS record
(if different from
  *Address Line 1:
  Address Line 2:
  *Zip: -
  *Contact Name:
  *Phone #: ()- Extension:
  Fax #: ()-
  Contact E-mail address::
Applicant Ordering Address:
  *Address Line 1:
  Address Line 2:
  *Zip: -
  *Contact Name:
  *Phone #: ()-Extension:
  Fax #: ()-
  Contact E-mail address::
Applicant Remittance Address:
  Please check all that
Woman Owned Minority Owned
Small Business Veteran Owned
  *1099 Withholding Type: 1099
1099 G
1099 I
Not subject to 1099 reporting because business is incorporated and not providing legal or medical services
  *1099 Withholding Class: Rents
Non-Employee Compensation
Gross Attorney Proceeds
Medical & Health Care
Other Income
(Default reportable status is Non-Employee Compensation)

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,
  2. AND
  3. I am not subject to backup withholding because:
    1. I am exempt from backup withholding, or
    2. 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
    3. The IRS has notified me that I am no longer subject to backup withholding, AND
  4. I am a U.S. citizen or other U.S. person (defined below).
    Definition of a U.S. Person. For federal tax purposes, you are considered a U.S. person if you are:
Electronic System Submission:
Under penalties of perjury I certify that:

* I am the same person (or payee’s agent) accessing the system and submitting this form as identified on the Substitute Form W-9.
* By submitting this form electronically, I am affixing my electronic signature as the payee identified on the Substitute Form W-9 and I am in agreement with DSHA to accept and process this transaction in electronic form.

"The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding."