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.  If you have questions completing this page in the form, please call: (612) 348-2976.

Required information is marked by a red asterisk (*)

 

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

 

Name. Do not use special characters in the name: \/"<>[]

Taxpayer Identification Number (TIN)

see www.naics.com/search for more information on NAICS codes

Direct Deposit (ACH) section

Automated Clearinghouse (ACH) Enrollment

Complete this form and return it to: 

OBF.Internet@hennepin.us

OR

Hennepin County - Accounts Payable

Government Center MC 131

300 South 6th Street

Minneapolis MN 55487-0131

Payee name. Do not use special characters in the name: \/"<>[]

This field aids in the 'connection' to the XDP radio buttons

I authorize Hennepin County and the financial institution listed below to initiate electronic credit entries and, if necessary, debit entries and adjustments for any credit entries in error to the account listed below for the purpose of receiving payment for billed goods/services. I understand that payment will be made by an ACH transaction and that the remittance information will be sent via email. Remittance information will not be provided in any other format. This authority will remain in effect until canceled in writing.

This field aids in the 'connection' to the XDP radio buttons

    If attaching an image or picture - please limit the file type to jpeg, jpg, gif.

    If attaching a PDF - please make sure the file type is pdf.

    HENNEPIN COUNTY CONTRACTOR DEMOGRAPHIC INFORMATION

    The information requested below is used internally by Hennepin County to monitor and report on participation in county contracting. Your cooperation in completing this form is greatly appreciated.  If you have questions completing this demographic information, please call: (612) 348-3181.

    Click the blue question marks on the right side of the page for more information

    If you chose one of these, continue to the next section.

    If you chose “all other” please answer all remaining questions.

    Small Business Enterprise Certification:

    Among other benefits, certification as a small business may provide your company access to contract opportunities advertised only to CERT certified small businesses.  For further information about certification, please call 651-266-8900 or visit https://cert.smwbe.com/

    Veteran-Owned Business Certification:

    For further information, please contact the Office of Equity and Procurement at: (651) 296-2600 or visit:https://mn.gov/admin/business/vendor-info/oep/sbcp/

    Ethnicity and Racial Group Definitions:

    Black/African American: All persons having origins in any of the Black racial groups of Africa.

    Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American descent or other Spanish culture of origin, regardless of race.

    Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Sub-continent or the Pacific Islands, including, for example, China, Japan, Korea, Hawaii, Guam, the Philippine Islands and Samoa.

    American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain tribal affiliation or community attachment.

    White/Caucasian: All persons with origins in any of the original peoples of Europe, North Africa or the Middle East.

    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.  If you are unable to check all three boxes, please call 612-348-2976.