IMPORTANT TAX INFORMATION - PLEASE READ THIS NOTICE CAREFULLY

This form was developed to comply with Internal Revenue Service (IRS) regulations and Minnesota statute and to assist Hennepin County in paying providers and vendors for their goods and services. You, as a payee, are required by law to provide us, as payer, your correct Taxpayer Identification Number (TIN). This information will only be shared with the IRS. The Minnesota Government Data Practices Act classifies the Social Security Number as private. Unless otherwise provided by law, the home address is also private. Direct questions to 612-348-2976.

Failure to respond to this request can result in IRS-mandated withholding on future payments as well as other penalties.



Taxpayer Identification Number (TIN)

Certification

Do not check the third box if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting of interest or dividends on your tax return.