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<br />.:t ~= 61'.1" <br />I ~ __ (Aev.1-9616) <br /> <br />TEXAS APPLICATION FOR PAYEE IDENTIFICATION NUMBER <br /> <br />1- <br /> <br />For Comptroller', us. only <br /> <br />II <br /> <br />. Shaded areas for state agency use only <br /> <br />. See Instructions on back <br /> <br />. PLEASE TYPE OR PAINT IN BLACK <br />INK YOUR NUMBERS LIKE THIS <br /> <br />011 23 Lf-ISIf,1718IQ <br /> <br />1, Is this a new account? <br /> <br />IUI VES Mail Code 000 <br />Complete Sections I . V <br /> <br />D NO Enler Mall Code ITIJ <br />Complele Sections I, /I. & V <br /> <br />Agency number ITIJ <br /> <br />_ 2. PAVEE IDENTIFICATION NUMBER (PINI . Indicalelhelype of number you are providing to be used for your PIN. <br />~ D 1 . Federal Employe(s Identificallon Number (FEIN) D 2 . Social Securily Number (SSN) D 3 - Complroller's assigned number <br />i= Enler number Indicated 17 5 6 01 0 10 I 613 15 <br />u <br />~ 3, Are you currently reporting any Texas tax to the Comptroller's office other than unemployment (e.g,. sales tax, franchise tax)? <br />!Xl YES D NO If .YES," enler Texas Taxpayer Number) __ _ __ __ 11 I 7 15 I 61 0 0 0 6 3 5 9 <br /> <br />C I T Y <br /> <br />o F <br /> <br />PAR I <br /> <br />~ <br /> <br />Please I O( ,int in all UPPER 'ASE Jeners as wn below. ONE character r box. <br />IA B CIDIE F GIHII J KILIMNOIPIQ R SITIU VIWIXIYZ <br /> <br />II I I <br /> <br />PAYEE INFORMATION <br />4. Name of Da ee indivlduel or business 10 be :>aId) <br /> <br />(This /s a continuous line of up to 50 charactBrs, LeavB only , space between names.) <br /> <br />= <br /> <br />5, Mailing address where you want 10 be paid <br />St"e1pO ROX QO'l7 <br /> <br />z <br />o <br />;: <br />u <br />w <br />Ul <br /> <br />Zoo. <br />0'" <br />CIt'lp I AIR I S I I I I I I I I I I I I I I I "".[ill ~~-EilJiUI1J <br /> <br />6, r-r-r-TI Payee telephone number ~/~ r::-r::T:T:l <br />SIC Code LLLL..J Securily Iype code D (0, 1, 2) (Area code and number) L:U.!.L.1.LJ LL.J...l1l.:l.J - l.LL...:l.lll-U <br />7, OWNERSHIP CODES. Check only one code by the approriata ownership type that applies to you or your business. <br />o S - Sole ownership (Individual owning a business) If checked, enler the owner's name and Social Security Number (SSN). <br />Owner's <br />Name <br /> <br />D <br /> <br />Social SecurUy Number <br /> <br />P - Partnerhsip - If checked. enter two partner's names and Social Security Numbers (SSN), If a partner is a corporation, use the corporation's <br />Federal Employer's Idontillcolion Number (FEIN). <br /> <br />Name <br /> <br />I <br />D SSN D FEIN D Complroller no. <br /> <br />Nom. <br /> <br />z <br />o <br />i= <br />o <br />w <br />Ul <br /> <br />D I - Individual Recipient (nol owning a business) <br />DE- <br /> <br />1 I I <br />D SSN D FEIN <br />DL- <br /> <br />o Comptroller no. <br /> <br />State Employee - If checked, entsr employing agency <br />number. ---------------- ITIJ <br /> <br />Limiled PMnership - If checked, enter Ihe Texas File Number. <br />I I <br /> <br />I II I I <br /> <br />o 0 - Out-ol-State Corporation <br /> <br /> <br />[2g G. Governmenlal Entlly <br /> <br /> <br />o U - State agency I University <br /> <br />o J - Joint Venture <br /> <br /> <br />o F - Financiallnstltutlon <br /> <br />D R - Foreign (out of U.S.A.) <br /> <br />o T - Texas Corporation - If checked, enter the Texas Charter <br />Number. ----- I I I I I I I I I <br /> <br />DA- <br /> <br />Professional Association - 11 checked, enter the Texas Chartsr <br />Number. n_n I I, I I I I I I I <br /> <br />o C - Professional Corporation - 11 checked. enter the Texas Charter <br />Number. n___ I I I I I I I I I <br /> <br />o N - Other - If checked, explain, <br /> <br /> ::: 8. Paymenl Asslgnmenl? DYES ~NO <br /> 0 Assignee PIN <br /> W I <br /> Ul <br /> .. Commenls <br /> > <br /> Z 10. sign~ AUI9;lign81 nt 0( lIuthrxlz90 llgenl) <br /> 0 <br /> ;: .:d ~" <br /> u here <br /> w 11. Agency nrwne <br />I Ul City of Paris <br /> <br />NOTE: A copy of the assignment agreement betwBen payses must be aUached. <br />Assignment dale (mmddyy) <br />ITIIIIJ <br /> <br />Pal. <br /> <br />Director of Finance <br />I Prepared by <br />R. Jones <br /> <br />June 22 1999 <br />Phone (At.. codfIand numbflr) <br />(903) 785-7511 <br /> <br />I <br />