NCC191283_Completed W9_20191119

NC Office of the STATE OF NORTH CAROLINA
,er..
State Controller SUBSTITUTE W-9 FORM
(IRS Form W-9 will not be �.
accepted In lieu of this form) Request for Taxpayer identification Number
"Denotes a Required Field
'1. Social Security Number (SSN),
Please select the appropriate Taxpayer Identification Number (EIN, SSN,
OR
or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer
Employer Identification Number (EIN),
Identification Number is being requested per U.S. Tax Law. Failure to
OR
provide this information in a timely manner could prevent or delay
Individual Taxpayer Identification Number (ITIN)
payment to you or require The State of NC to withhold 28%for backup
"2. 56-0964185
withholding tax.
'4. Legal Name (as shown on your income tax return):
3. Dunn & Bradstreet Universal Numbering System IDUNS) (see
James R. Vannoy & Sons Construction Company Inc
instructions)
S. Business Name/DBA/Disregarded Entity Name, if different from
00-678-0662
Legal Name:
C
Contact Information
'6. Legal Address
7. Remittance Address (Location specifically used for payment that Is
u
PO BOX 635
different from Legal Address, If applicable)
tC
"Address tine 1:
Address Line 1:
c
1608 US H 221 North
d
v
Address Une 2:
Address Line 2:
:a.
"cisy `state *Zip (9 digit)
city State tip (9 digit)
CL
Jefferson NC 28640
h'county
I
Ashe
county United States
ry
S. Contact Name:
CPhone
Number:
j?
ID. Fax Number:
N
11. Email Address:
'12. Entity Type
•13. Entity
14. Exemptions (see
Classification
Instructions)
Individual/Sole Proprietor/Single-member LLC ❑C-Corporation IRS -Corporation
❑ Medical Services
Partnership Trust/Estate Other
❑ Legal/Attorney
Exempt payee code (if any):
Services
Limited liability company. Enter the tax classification (C=C corporation,
NC Local Gavt
❑ '
S=S corporation, P=Partnership)
❑ Federal Govt
Note: Check the appropriate box In the line above for the tax classification of the single-
❑ NC State Agency
member owner. Do not check LLC if the LLC is classified as a single -member LLC that is
Exemption from FATCA
disregarded from the owner unless the owner of the LLC is another LLC that is not
❑ Other Govt
reporting code (if any):
disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC
Other (specify)
that is disregarded from the owner should check the appropriate box for the tax classification
of its owner.
Under penalties of perjury, I certify that:
pt.
The number shown on this form is my correct taxpayer identification number (or l am waiting for a number to be issued to me), and
2. 1 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
u
(IRS) that I am subject to backup withholding because of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer
92
subject to backup withholding, and
W3.
1 am a U.S. citizen or other U.S. person (defined later in general Instructions), and
ti
,
4. The FATCA code(s) entered on this form (if any) Indicting that I am exempt from FATCA reporting is correct.
N
O
Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website (h s•//vrww irs ¢ovQ:
*Printed Name:
Y
'Printed Title: �A.
'Authorized U.S.
*Date: tl
ty
Signature:
I q
Please complete the "Modification to Existing Vendor Records" section below If thFrelhave been any changes to the following: Tax Identification Number (TIN),
Legal Name, Business Name, Remittance Address o
Return to the NC State Agency from which you are requesting payment.

INC Office of the STATE OF NORTH CAROLINA
State Controller SUBSTITUTE W-9 FORMr r 1=
*Denotes a Required Field
This form is to be Modification to Existing Vendor Records -
completed by the vendor.
This form is to be completed by the vendor if one or more of the following have changed:
1. Change of remittance address.
2. Change of Social Security Number (55N), or Employer Identification Number (EIN), or Individual Taxpayer
Identification Number (ITIN).
3. Change of Vendor Name.
Please complete the applicable sections below.
Section 1:
CHANGE FROM: Remittance Address
*Address Line 1:
Address Line 2:
*City 'State *Zip (9 digit)
*County
Section 2:
CHANGE TO: Remittance Address
`Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
'
'County
NOTE: If you would like to receive your payments electronically, please
complete the Vendor Electronic Payment Form
* CHANGE FROM: SSW, or EIN, or ITIN * CHANGE TO: SSN, or EIN, or ITIN
Section 3:
CHANGE FROM: Vendor Name
*Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
CHANGE TO: Vendor Name
*Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
*Printed Name:
*Printed Title:
*Authorized U.S.
Date:
Signature:

NC Office of the State Controller Substitute W-9Instructions Page 1
General instructions
For General Instructions, please refer to the IRS Form W-9 located an the IRS Website lhttos://wwwirs.¢ov/I.
Specific Instructions
Section 1-Taxpayer Identification
1. Taxpayer Identification Type. Check the type of Identification number provided in box 2.
2. Taxpayer Identification Number(TIN). Enter taxpayer's nine -digit Employer Identification Number(EIN), Social Security Number(SSNI, or Individual Taxpayer
Identification Number (ITIN) without dashes.
Note: If an LLC has one owner, the LLC's default tax status is "disregarded entity". If an LLC has two owners, the LLC's default tax status Is "partnership". [fan LLC has
elected to be taxed as a corporation, It must file IRS Form 2553 IS Corporation) or IRS Form 8832 (C Corporation).
3. Dunn and Bradstreet Universal Numbering System(OUNS). Vendors are requested to enter their DUNS number, if applicable-
4. Legal Name. Enter the legal name as registered with the IRS or Social Security Administration. In general, enter the name shown on your income tax return. Do
not enter Disregarded Entity Name on this line.
S. Business Name. Business, Disregarded Entity, trade, or DBA ("doing business as") name.
Contact Information
6. Enteryour Legal Address.
7. Enter your Remittance Address, if applicable. A Remittance Address is the location In which you or your entity receives business payments.
8. Enter the Contact Name.
9. Enter your Business Phone Number,
10. Enter your Fax Number, If applicahle.
11. Enter your Email Address, if applicable.
For clarification on IRS Guidelines, see www.irs.gov.
12. Entity Type. Select the appropriate entity type.
13. Entity Classification. Select the appropriate classificationtype.
Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and
Exemption from FATCA reporting code below.
14. Exempt payee code. Generally, individuals (Including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as Interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of
payment card or third party network transactions.
Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.
The following codes Identify payees that are exempt from backup withholding:
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 possession of the United States, 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 possession of the dnited States
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.

NC Office of the State Controller Substitute W-9Instructions Page 2
The following chart shows types of payments that maybe 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
Broker transactions
Exempt payees 1 through 4 and 6 through
11 and all C corporations. 5 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
Exempt payees i through 4
dividends
Payments over $600 required to be reported and
Generally, exempt payees 1 through 5'
direct sales over $5,0001
Payments made In settlement of payment card
Exempt payees lthrough 4
or third party network transactions
See Form 1099-MISC, Miscellaneous Income, and its Instructions.
2 However, the following payments made to a corporation and reportable on Form 1099-MISCare not exemptfrom backup withholding: medical and health care
payments, attomeys' fees, gross proceeds paid to an attorney, 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- 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 possession of the United States, or any of their political subdivisions or instrumentalities '
D - A corporation the stork of which is regularly traded on one or more established securities markets, as described in Reg. 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 Reg. section 1.1472-11c)(1)(1)
F- Adealer 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
1 - A common trust fund as defined in section 584(a)
1- A bank as defined in section 581
K-A broker
t- A trust exempt from tax under section 664 or described in section 4947(al(i)
M - A tax exempt trust under a section 403(b) plan or section 457(g) plan
Section 2 - Certification
To establish to the paying agency that your TIN Is correct, you are not subject to backup withholding, oryou are a U.S. person, or resident alien, sign the certification
on NC Substitute Form W-9. You are being requested to sign by the State of North Carolina.
For additional Information please refer to the IRS Form W-9 located on the IRS Website (httpv//www.irs.gov/1.